
Class ^F4 6 

Book V F&7 
Gofpglil X" 

COPYRIGHT DEPOS1 




VERTICAL ANTEROPOSTERIOR SECTION OF 
UPPER RESPIRATORY TRACT. 



DISEASES 

OF THE 

Nose, Throat and Ear. 



FOR STUDENTS AND PRACTITIONERS IN WHICH 

PARTICULAR ATTENTION IS GIVEN THE 

TREATMENT OF DISEASES BY 

ECLECTIC MEDICATION 



BY 

KENT O. FOLTZ, M. D. 

Professor of Ophthalmology, Otology, Rhinology and Laryngology in the 

Eclectic Medical Institute, Cincinnati ; Assistant Editor the Eclectic 

Medical Journal ; Author of a Manual on Diseases of the Eye. 



ILLUSTRATED. 




(I NCINNATI: 

THE SCUDDER BROTHERS COMPANY 

1906. 



LIBRARY of CONGRESS 
Two C«oies Received 

| JUL 16 190 6 

^Copyright Entry 
t^CL> XXfc- N0.I 

iLf-C 7 /7 

COPY B. 



Copyrighted, 1906, by 
The Scudder Brothers Company. 



TO THE 
MEMORY OF MY FATHER, 

minm %. Jffelfe, JR. ^ 



INTRODUCTION. 



I HAVE no apology to offer for this book. For some 
unaccountable reason there has been a tendency among 
writers on these subjects to ignore practically everything 
but local measures in treating the conditions which are so 
prevalent in the upper respiratory tract and the structures 
more or less directly dependent upon this region for their 
proper functional action. Why-, with a few notable ex- 
ceptions, internal medication has been ignored, is impos- 
sible to say. In the majority of inflammatory conditions 
of the upper respiratory tract and the ears, if proper 
systemic measures are instituted during the second stage, 
a cure will result. Later, relief is in many cases all that 
can be expected, but this can not be obtained by the use 
of sprays, gargles, douches, etc., excepting a very transi- 
tory amelioration of the condition. Proper constitutional 
measures will give more or less permanent relief in prac- 
tically all but malignant cases. 

My experience has been that the selection and admin- 
istration of drugs from the Eclectic standpoint of specific 
medication will give more satisfactory results than the 
generally-accepted method of local treatment only. How- 
ever, to follow the precepts of specific medication, specific 
diagnosis is of the utmost importance, and it has been my 
aim to emphasize these features in this volume. The in- 
dications for the use of drugs have been as explicit as 
seemed necessary. 



8 Introduction. 

It must not be inferred that no other drugs are re- 
quired in treating these diseases, but the ones mentioned 
are the basis of treatment, and it is presumed the prac- 
titioner will use such other remedies as may be indicated, 
common sense being a requisite in handling specialties as 
well as in general practice. A knowledge of embryology 
will be an aid to a more comprehensive study of morbid 
changes in these structures, and I can not too strongly in- 
sist upon this important branch of biology being given 
more attention. 

The liquid drugs employed are the product of the 
laboratory of Lloyd Brothers, viz., specific medicines, un- 
less otherwise stated. The preference is given these on 
account of the uniformity of strength and because I have 
been able to get results from these preparations that I 
could not always obtain from other tinctures. 

I wish to thank W. B. Saunders & Company for per- 
mission to reproduce several plates ; also Max Wocher & 
Sons Company for the use of cuts of instruments. I also 
wish especially to thank Miss Margaret Stewart for assist- 
ance in proofreading, and Miss Tillie K. Hannah for work 
on the manuscript. I have endeavored to give credit to 
the different authors throughout the body of the work, 
but some of the investigations referred to were in journal 
articles where the name had inadvertently been lost or 
overlooked. 

As for the style of the book, the author has endeav- 
ored to state the subject clearly and concisely, often at the 
expense of smoothness, but with a desire to impress the 
important points in making the diagnosis and prescribing 
the proper remedies. 



The Upper Respiratory Tract. 



CHAPTER I. 
THE NOSE. 

ANATOMY. 

THE nose is divided into the external and internal por- 
tions. The nasal organ possesses several functions. 
The external portion being necessary only for the adorn- 
ment of the face, while the internal is for the distribution of 
the olfactory nerve, and also constitutes the upper portion 
of the respiratory tract. The peculiar anatomical structure 
not only prepares the inspired air for entrance into the lungs, 
but supplies the necessary moisture, regulates the tempera- 
ture, and also removes the coarser foreign material usually 
floating in the atmosphere. From the arrangement of not 
only the olfactory, but also the other nerves in the nasal 
cavity, a warning of the presence of injurious substances 
is often given. What is also of especial importance, is the 
power to determine the properties and character of food 
and drink, as the nasal region is actually the seat of what 
is usually called the sense of taste. 

The embryologicai development of the nose in detail is 
not perfectly understood, but the structures derived from 
the ectoderm are, the integument ; vibrissas ; sebaceous and 
sweat glands ; the nasal mucous membrane, including the 
glands and mucous membranes of the accessory nasal cavi- 
ties. The nervous tissues are also derived from this layer, 
as well as the sensory epithelia of the special sense organs. 



io Nose, Throat and Ear.' 

The mesoderm supplies the muscular and adipose tissue, 
cartilages and bony structures. 

Besides the division into the external and internal- por- 
tions, another division of this tract is made, posterior or 
postnasal space, sometimes called the vault of the pharynx. 
In front of this portion is the anterior region, which is di- 
vided into two fossae by the septum. These fossa? extend 
from the postnasal space forward to the nostrils. Each 
fossa is bounded internally by the septum, which is formed 
by the perpendicular plate of the ethmoid and spine of the 

DIVISION OF NOSTRILS. 'Septum Narium.) 



Sjtina nasal.su 
oss. front. 

Os nasalt 




Cart. 

Can. naso-patat.- 

FlG. 2. 

frontal bone above, posteriorly by the vomer, and anteriorly 
by cartilage. The septum is generally perpendicular until 
about the seventh year; after this age deviation often 
occurs and generally to the left. The anterior and posterior 
portions of the roof slope downward, the central portion 
being nearly horizontal. The roof consists of the nasal 
process of the frontal and nasal bone in front, the central 



The Nose. 



n 



portion by the cribriform plate of the ethmoid and the 
posterior part by the inferior surface of the sphenoid and 
the sphenoidal turbinates. 

The anterior three-fourths of the floor consists of the 
palate process of the superior maxillary; the posterior por- 
tion of the horizontal plate of the palate bone. 

The outer anterior wall is formed by the nasal process 
of the superior maxillary and lacrimal bones, the middle 
portion by the ethmoid and inner surface of the superior 




Fig. 3. 

maxillary and inferior turbinates, and posteriorly by the 
vertical plate of the palate and internal pterygoid plate of 
the sphenoid bone. Extending from the bony walls to the 
nostrils, the fossae are called the vestibules, the outer wall 
of each vestibule is formed by an upper and lower lateral 
cartilage, and two or three smaller plates of cartilage, the 
inner wall being formed by the triangular cartilage of the 
septum. Each fossa contains three, and sometimes four, 
thin, somewhat triangular bony structures, which extend 
from the outer wall toward the median line, but do not come 



12 



Nose, Throat and Kar. 



in contact with the septum. These bony processes are the 
turbinated bodies, and are more or less curved, the convex 
surface being upward, inward, and somewhat forward. The 
line of attachment of each is approximately horizontal and 
are nearly equidistant from each other. 



Cell, 
Sulc. ethmoidal 
Olfact. post. 

Sinus front. 



K 



i & 




yyfl^ 



1 Optic nerve. 



Cell, ethmoidal, 

posterior. 
Middle meatus. 

Cell, middle tur- 
binate. 

Maxillary sinus. 

I Inferior turbi- 
nate. 



Septum Molar, 
narium. 

Fig. 4. This section is made vertically through the nasal cavi- 
ties and maxillary antra on a plane with the first molars. The arrow 
on the right side indicates an accessory maxillary opening. On the 
left side are seen the posterior ethmoidal cells opening into the ol- 
factory cleft, and a middle turbinate cell into the middle meatus. 
The frontal sinuses are shown extending backwards along the or- 
bital roof. 

The superior turbinate, which is the smallest, is often 
divided horizontally, thus forming the fourth turbinate, or 



The Nose. 13 

''concha Santoriniana." The superior turbinate originates 
from the lateral mass of the ethmoid, and projects down- 
ward nearly perpendicularly. The anterior margin is coa- 
lescent with the middle turbinate, the posterior being free. 

The middle turbinate is from the lateral mass of the 
ethmoid, is of larger size, more rolled at the center and 
projects horizontally. The anterior free margin presents 
the "agger nasi," a slight elevation projecting downward, 
and is opposite a corresponding septal elevation. These are 
important, marking the boundary between the olfactory re- 
gion above and the respiratory tract below. 

The inferior turbinate, as the name indicates, is the low- 
est; and also the largest. Its structure is more compact, and 
it is a separate bone. It articulates with the ethmoid, supe- 
rior maxillary, palate, and lacrimal bones. 

The space comprised between each pair of turbinates, 
and between the inferior turbinate and floor of the nose, is 
called a meatus, and according to location are designated as 
superior, middle, and inferior. If through division of the 
superior turbinate a fourth meatus is formed, it is disre- 
garded, as it is of no particular importance. 

Communicating with the meatuses are the accessory si- 
nuses, and as a result of this communication any of these 
sinuses may become affected in morbid conditions of the 
nasal fossae through the continuity of tissue. These si- 
nuses form four, groups : the sphenoidal, ethmoidal, frontal, 
and maxillary, or antra of Highmore. 

The sphenoidal sinuses, or cells, are two irregular cavi- 
ties in the body of the sphenoid, separated from each other 
by a thin bony septum. They vary in size and are not de- 
veloped in infancy, but at about the age of three years begin 
forming, and increase in size with advancing age. In front 
and below they are partially closed by two thin plates of 
bone, the sphenoidal turbinated bones, round openings be- 
ing left at their upper parts, which are located in the upper 



14 



Nose, Throat and Ear. 



and posterior portion of each superior meatus. The roof of 
the sinuses, which separates them from the brain, is about 
I- 12 of an inch thick at the thinnest part. 




Fig. 5. Vertical section of skull, showing the right accessory si- 
nuses, about two-thirds natural size. (1) Left frontal sinus, separated 
from right frontal sinus (2) by bony septum ; (3) Crista galli ; (4) 
Cribriform plate; (5) Sella turcica; (6) Optic foramen; (7) Sphe- 
noidal sinus ; (8, 9) Posterior ethmoidal cells ; (10) Portion superior 
turbinate; (n) Portion middle turbinate; (12) Superior meatus; 
(13, 14) Anterior ethmoidal cells ; (15) Bulla ethmoidalis; (16) Pro- 
cessus unciformis ; (17) Ostium maxillare; (18) Spheno-palatine 
foramen; (19) Portion inferior turbinate; (20) Location of nasal 
orifice of nasal duct in inferior meatus ; (22) Fronto-nasal duct ; (23) 
Inferior meatus ; (24) Sphenoid bone. The dotted line extends from 
the nasal orifice to the posterior wall of the sphenoidal sinus. 



The Nose. 15 

The ethmoidal sinuses, or cells, are located in the lateral 
mass of the ethmoid, and consist of a number of thin walled 
cellular cavities, which are enclosed between two vertical 
plates of bone, the external of which forms part of the orbit, 
and the internal part of the nasal fossa of the correspond- 
ing side. These cells are divided anatomically into the an- 
terior, middle, and posterior. The anterior cells, which are 
the most numerous, open into the infundibulum, or canal, 
from the frontal sinus, by means of small openings, ostia 
ethmoidalia, reaching the middle meatus at the hiatus semi- 
lunaris in its extreme anterior part. The posterior cells 
open into the superior meatus and sometimes connect with 
the sphenoidal sinus. In some instances the anterior cells 
may open into the frontal sinuses or even into the orbit. 

The frontal sinuses are two irregular cavities, and are 
larger than the sphenoidal ; they are situated in the frontal 
bone over the anterior portion of the nasal cavity, and ex- 
tend laterally over the orbits, forming the prominences over 
the supraorbital arches, the superciliary ridges, and also 
form the prominences over the root of the nose. These 
sinuses, like the sphenoidal, are usually absent in children, 
but develop with advancing years. They are larger in men 
than in women, and the right is usually the largest. The 
sinuses are separated by a bony lamina, which is often de- 
flected, usually to the opposite side from the septal devia- 
tion. 

The maxillary sinuses, or antra of Highmore, are sit- 
uated one in each superior maxillary bone, and are some- 
what pyramidal in form. The apex of each is directed out- 
wards and is formed by the malar process ; the base by the 
outer wall of the nose ; the roof by the orbital floor, and the 
floor by the alveolar process. The external wall is the faeial 
surface, and the posterior wall the zygomatic surface of the 
maxillary. Each maxillary sinus connects by a circular 
opening with the middle meatus near the posterior part of 



i6 



Nosk, Throat and Ear. 



the hiatus semilunaris. The opening is called the ostium 
maxillare. A secondary opening, situated behind this, is 
sometimes present and is called the ostium maxillare acces- 




Antrum of 
Highmore 



Fig. 6. The external bony wall is removed to show the relation 
of the roots of the teeth to the antral floor. 



sorius. Racial as well as individual differences are found 
to influence the size of these cavities. Thin laminae of bone 
frequently cross these sinuses. The nerves of the teeth and 



The Nose. 17 

posterior dental vessels are contained in canals situated in 
the posterior wall, while the floor is frequently irregular 
through encroachment of the first and second molars. 

The anterior portion of the inferior meatus contains 
the opening of the nasal duct, which is more or less closed 
by the valve of Hasner. This duct represents the lower por- 
tion of the lacrimal drainage apparatus, being a downward 
continuation of the lacrimal sac. 

The mucous membrane of the accessory cavities varies 
somewhat from that of the nasal fossae. The epithelial lin- 
ing is composed of a single layer of pavement epithelium. 
The basement membrane and submucosa are thinner than 
in the exposed regions, while the glands are more numerous 
at the openings into the nasal fossae. As all portions of the 
body, which communicate with the atmosphere are lined 
with mucous membrane, differentiated according to the 
character of the work required, it becomes necessary to 
study each region separately. 

The variation in the character of the epithelium is a bar 
to the ready extension of inflammatory action, although 
through continuity of tissue, one would suppose that no 
hindrance would be interposed. The walls of the nasal 
fossae are lined with mucous membrane continuous in front 
at the nostrils with the skin, posteriorly with the pharyngeal 
mucous membrane. The nasal mucous membrane is 
variously designated as the pituitary, nasal mucosa, or 
Schneiderian membrane, and varies in its characteristics 
according to location, and also changes the lumen of the 
nasal fossae, the accessory cavities and their openings as 
compared with the denuded skull. The membrane is thick- 
est on the convex surface of the turbinates, and quite thin 
on the floor of the nose and accessory sinuses. 

The membrane varies in color according to location. It 
is a yellowish pink in the olfactory, or upper portion, which 
includes the roof and superior turbinates, superior meatus, 
2 



18 Nose, Throat and Ear. 

upper third of the convex surface of the middle turbinates, 
and the corresponding part of the septum. The lower, or 
respiratory portion, presents a light pink color, the posterior 
ends of the turbinates being whitish. The color of the mem- 
brane in the accessory cavities is a pale pink. These tints 
\ary in different individuals, as well as in various systemic 
conditions, and the character of the light used in the exam- 
ination will also cause a difference in the appearance. 

The respiratory, exposed, or epithelial portion, ectoder- 
mic in origin, consists of the stratified ciliated columnar 
type, goblet cells being distributed throughout the super- 
ficial layer. The second layer, mucosa or tunica propria, 
consists of fibrous connective tissue. Lymphoid tissue 
nodules are found in this portion. The surface of the 
tunica propria 'is smooth through lack of sub-epithelial 
papillae. Small racemose glands opening on the free sur- 
faces of the membrane are numerous and may be detected 
by macroscopic inspection. These are mucous glands, some 
secreting serous fluid and some mucous secretion. The 
glandular elements are most freely distributed over the in- 
ferior turbinates, but the external walls and lower portion 
of the septum are also freely supplied. 

The third, or inner layer, as usually designated, con- 
sists of the veins of the mucosa, which are so numerous and 
wide that this region is often spoken of as cavernous, or 
erectile tissue, and when the veins become engorged with 
blood, the fossae may be nearly or entirely occluded. 

The olfactory surfaces differ from the respiratory, not 
only in color as already mentioned, but in the character of 
the epithelial cells, which are sustentacular or support cells, 
and olfactory elements, and also the tunica propria. The 
sustentacular cells consist of an outer cylindrical division. 
Near the inner end of each cell there is an oval nucleus. In 
the same location yellowish pigment, and numerous gran- 
ules are arranged, forming more or less distinct rows. The 



The Xose. 19. 

round nuclei of the olfactory cells forms a broad zone ad- 
joining the band of oval nuclei. 

The olfactory cells are inconspicuous, elongated, at- 
tenuated bodies, surrounded by the supporting elements. 
The nuclei of the olfactory cells are at different levels. The 
deepest part consists of small nucleated cells forming the 
inner boundary of the epithelial layer, and rests upon the 
tunica propria. The tunica propria in this region consists 
of fibrous connective tissue, in bundles, as well as delicate 
elastic fibers. The mucosa contains numerous branched 
tubular or Bowman's glands. 

The veins of the nasal mucous membrane are numerous 
and of large size, especially over the posterior part of the 
inferior turbinates. The arterial system is in the deeper 
layers of the tunica propria, sending branches to the super- 
ficial layers, where the sub-epithelial capillary net- work is 
formed. 

The lymphatic circulation is maintained by a net work of 
numerous vessels around the lymphoid nodules and in the 
deeper portion of the tunica propria. In the olfactory re- 
gion perineurial lymph channels form a net work in the 
mucosa. 

The nerve supply of the nasal mucous membrane con- 
sists of the nerves of common sensation and the special, or 
olfactory sense. The larger filaments of the olfactory nerve 
lie in grooves in the bony walls, and give off smaller bundles 
which pass toward the epithelial surface. Perineurial 
sheaths, prolongations from the intercranial investment of 
the olfactory nerve, are often found in the mucosa surround- 
ing the nerve twigs. When the epithelium is reached, the 
nerve fibers divide into their component fibrillar and pass 
as naked, often varicosed axis-cylinders between the ele- 
ments of the neuro-epithelium. The fibrillar probably are 
in close contact or continuous with the inner ends of the 
olfactory cells. The trifacial nerve also supplies some 



20 Nose, Throat and Ear. 

medullated fibers to the olfactory region, but these probably 
do not come into direct relation with the olfactory cells. 
The membrane lining the vestibule is cutaneous in charac- 
ter, the epithelium being squamous. 

Blood Supply. — Each fossa receives its blood from the 
spheno-palatine branch of the internal maxillary, and a small 
vessel from the small meningeal branch of the internal 
maxillary, and the anterior and posterior ethmoidal branches 
of the ophthalmic. The artery of the septum from the supe- 
rior coronary and the alveolar branch of the internal maxil- 
lary which supplies the membrane lining the maxillary an- 
trum. The spheno-palatine enters the fossa just back of 
the superior meatus, through a foramen of the same name, 
and divides into an internal and external branch, the first, 
the naso-palatine, or superior artery of the septum, passes 
downwards and forwards along the septum, supplying the 
membrane. The external sub-divides into several branches 
and supplies the lateral mucous membrane, the antrum, 
sphenoidal, and ethmoidal sinuses. The anterior and poste- 
rior ethmoidal arteries enter the corresponding ethmoidal 
cells, and are distributed throughout the cavities, they then 
enter the cranium, dividing into smaller nasal branches, and 
pass through the cribriform plate of the ethmoid and down 
the walls of the fossa a short distance. The frontal sinuses 
are also supplied by the anterior branches. The anterior 
portion of the septum receives its supply from the septal 
artery, a branch of the superior coronary of the facial which 
enters the nose at the junction of the nostril and lip. The 
free anastomosis and profuse arterial supply renders most 
operative procedures in this region very annoying, on ac- 
count of the excessive hemorrhage. 

Nerves. — The olfactory nerves proceed from the under 
surface of the olfactory bulb, and passing through the 
foramina in the cribriform plate, divide into three more or 
less distinct sets, the inner distributed to the upper third of 



The Nasopharynx. 21 

the septum ; the outer supplying the superior turbinate, the 
olfactory portion of the middle turbinate, and the ethmoidal 
surface anterior to them ; the middle division supplying the 
roof between the distribution of the other two. The spheno- 
palatine ganglion of the sympathetic supplies branches which 
are distributed to the upper, middle, and posterior parts of 
the septum, the lower edges of the superior and the sur- 
faces of the middle inferior turbinates. 

General sensation results from the distribution to the 
upper and anterior part of the septum, the nasal floor, outer 
walls and anterior surfaces of the inferior turbinates of the 
nasal branches of the fifth pair. The inferior turbinate and 
inferior meatus by filaments from the anterior dental branch 
cf the superior maxillary ; the upper and back part of the 
septum and superior turbinate by the Vidian nerve. 

The Naso-Pharynx, or Post-Nasal Space. 

This comprises the portion of the upper respiratory tract 
between the plane of the superior nares and the plane extend- 
ing horizontally backward at the level of the free margin of 
the soft palate. In front it is continuous with the nasal fossae, 
below with the oropharynx, and on the sides with the tym- 
panic cavities through the Eustachian tubes. The roof 
slopes from the upper borders of the nasal fossae in front to 
the posterior and lateral walls, forming a dome-shaped cav- 
ity, the dome or vault of the pharynx. The bony borders 
are, above the vault of the pharynx, the body of the sphenoid 
and basilar process of the occipital bone with the so-called 
basilar fibro^cartilage. Behind is located the first cervical 
vertebra, and laterally the internal pterygoid plates of the 
sphenoid and petrous portions of the temporal. Anteriorly 
by the posterior bony margins of the nasal cavities. 

The tissues of this region are divided into mucous, 
fibrous, and muscular. The epithelium of this region is 
stratified ciliated columnar, with goblet cells interspersed, 



12 Nose, Throat and Ear. 

but the portion below the level of the soft palate is stratified 
squamous cells, similar to those found in the oral cavity. 
The tunica propria consists of fibrous bundles with a varia- 
ble amount of elastic tissue, sometimes called the pharyn- 
geal aponeurosis. Numerous small papillae are contained in 
the sub-epithelial surface of the mucosa, which is covered 
by the squamous cells, but they are absent beneath the 
ciliated epithelium. Small mucous pharyngeal glands are 
found in many places, being especially numerous in the 
deeper layers of the mucosa surrounding the mouths of the 
Eustachian tubes. In the upper part of the cavity, arranged 
as lymph follicles, is a quantity of adenoid tissue, which is 
especially prominent in the posterior pharyngeal wall be- 
tween the orifices of the Eustachian tubes. This is called the 
pharyngeal, or Euschka's tonsil, on account of the similarity 
of structure to the faucial 'tonsils. This structure extends 
in both directions from the median line to a marked de- 
pression, Rosenmuller's fossa, or recessus pharyngeus, 
which separates it from the orifice of the Eustachian tube. 
The fossa is important in locating the mouth of the tube. 
The surface of the mass is more or less irregular on account 
of the depressions formed by the lacunae or crypts and the 
minute elevations representing the glandular openings. A 
slit-like orifice in the lower part leading to a small sac be- 
neath, which Euschka calls the pharyngeal bursa, is found 
in the majority of cases. The mucous membrane is con- 
nected with the fibrous coat by sub-mucous tissue. The pos- 
terior part of the fibrous coat is thickened, forming a raphe, 
which serves as an attachment for the constrictor muscles. 

The muscular coat, consisting of striped fibers, com- 
prises the constrictor and other muscles of this region. Ex- 
ternal to this, areolar tissue of varying thickness forms the 
attachment for the surrounding structures. The color of 
the mucous surface in the vault is a deeper pink than that 
of the nasal fossae. Around- the Eustachian eminences it 



Fauces axd Oropharynx. 23 

is a lighter color, shading to a yellowish tint surrounding 
the orifices. 

Blood Vessels. — The arteries supplying this region are 
derived from the external carotid. Branches of the ascend- 
ing pharyngeal being distributed to the greater part. The 
anterior portion is supplied by the terminal branches of the 
descending palatine, and spheno-palatine from the internal 
maxillary. The soft palate and the palatine glands are sup- 
plied by the ascending palatine branch of the facial. The 
venous return is through sub-divisions of the internal jugu- 
lar vein. 

Nerve Supply. — Branches of the second division of the 
fifth nerve supply the greater portion. Branches from the 
glossopharyngeal, spinal accessory, and the superior cerv- 
ical ganglion of the sympathetic through the pharyngeal 
plexus. 

The lymphatics are very numerous in the vicinity of the 
lymph follicles, forming net works which are continuous 
with those of the nasal fossae, esophagus and larynx. 

Fauces and Oropharynx. 

The roof of the oral cavity is formed by the hard 
palate anteriorly and the soft palate posteriorly. The 
hard palate is confined in front and on the sides by 
the alveolar processes, behind being continuous with the 
soft palate. The mucous membrane of the hard palate 
is thin and closely adherent to the periosteum, form- 
ing a firm resisting membrane. Corresponding to the suture 
of the palatal bones is a ridge, which terminates anteriorly 
in a small papilla corresponding to the orifice of the anterior 
palatine fossa. On each side of the median line, the mucous 
membrane presents a corrugated or rugose appearance, and 
is covered by squamous epithelium. Glands in this region 
are limited in number. The soft palate, or velum, is a pen- 
dulous body and consists of muscular tissue enclosed in 



H 



Nose, Throat and £ar. 



mucous membrane, it is attached to the posterior portion of 
the. hard palate and partially separates the mouth from the 
pharynx. The sides merge with the faucial pillars, but the 



PHARYNGEAL MUSCLES 




oss. hyo 



Cart. 

Writ 



Cart 
vantorin 



Posterior view. (Pharynx opened) 

Fig. 7. 

lower border is free. As a rule, the raphe of the soft palate 
is not as marked as that of the hard palate. 

The muscles consist of five pairs : the levator palati, ten- 
sores palati vel dilator tubse; the palato-glossi, which not 



Tonsils. 25 

only form the anterior pillars of the fauces, but also act as 
constrictors of the fauces ; the palato-pharyngei, which form 
the posterior pillars and the azygos uvulae, consisting of a 
pair of cylinder-like bundles placed side by side and parallel 
to the median line of the velum. This pair of muscles with 
the connective and glandular tissue forms the elongated 
portion called the uvula. The functions of the palatal mus- 
cles are aids in deglutition and vocalization, while the ten- 
sor and levator influence the opening of the Eustachian 
tube allowing free ventilation of the tympanic cavities, and 
for this reason play an important part in normal hearing. 

The action of the uvula has been a matter of much specu- 
lation, it undoubtedly acts as a drag or anchor in the act 
of swallowing, preventing the velum from passing upward 
into the post-nasal space which would allow food and fluids 
to enter the nasal fossae. It also, probably, in connection 
with the rest of the palatine tissues and epiglottis, partially 
occludes the oral cavity from the respiratory region in nor- 
mal breathing. Another function may be that of directing 
the nasal secretions to the glosso-epiglottic fossae. (Dobell). 
When much relaxed or absent, either through ulceration or 
a faulty operation, phonation is not distinct, and swallowing 
is liable to be followed by the passage of food into the nasal 
space. Paresis of the palatal muscles is generally present 
when the uvula is much elongated or absent. 

Tonsils. 

The tonsils represent compound lymphatic glands. 
The size and shape varies, although they approximate 
an obovate form, and consist of from ten to eighteen 
lymph follicles contained within a diffuse adenoid tissue. A 
fibrous capsule not only envelops the mass, but serves to sepa- 
rate it from the surrounding tissues. The oral epithelium is 
continuous on the mucous surface. Lymphoid cells are dis- 
tributed throughout the epithelium covering the folds and 



26 Nosh, Throat and Ear. 

depressions of the gland. Mucous glands are numerous in 
"the vicinity of the tonsils, which are situated in the faucial 
ring and occupy a portion of the triangular space formed 
by the anterior and posterior pillars of the fauces. The 
free surface projects into the faucial isthmus. The supra- 
tonsillar fossa is a variable depression lying behind the an- 
terior pillar. 

The tonsil is usually separated from the pharyngeal por- 
tion of the tongue by a deep sulcus which may be obliterated, 
giving then a continuous appearance to the lingual and 
faucial tonsils. Externally the location of the faucial ton- 
sil is determined by having the head in the normal position, 
then a spot corresponding to the interval between the angle 
of the inferior maxillary and the sterno-cleido-mastoid mus- 
cle, and the tip of the great cornu of the hyoid bone will be 
over the gland. Inward pressure on the neck at this point 
with the finger will press the tonsil towards the median line, 
thus facilitating tonsillotomy. External to the tonsil is a 
strong fibrous membrane, a portion of the amygdalo-epiglot- 
tic fold, which here lines the fossa of the tonsil. Next to 
this membrane lies the superior constrictor muscle. These 
two structures are all that separate the tonsil from the 
sheath of the internal carotid artery. As a result of this 
thin barrier, motion is often imparted to hypertrophied or 
inflamed tonsils by the pulsation of the artery. 

Arteries. — The arterial circulation is derived from the 
facial by the ascending palatine and its tonsillar branches ; 
the lingual ; and the ascending pharyngeal. In some cases 
also there are twigs from the descending palatine, a branch 
of the internal maxillary. The proximity of the carotid, 
ascending pharyngeal, and ascending palatine, should be 
remembered in operative measures. The lingual artery also 
passes forward close to the lower end of the tonsil, and. com- 
pression may easily be made at this point. 

The veins correspond to the arteries, but form a net 



The Pharynx. 27 

work on the external or carotid side before accompanying 
their respective arteries. Large branches from this net work 
also pass to the pterygoid and post-pharyngeal -veins. 

Lymphatics are numerous and are divided into super- 
ficial and deep, they perforate the pharyngeal wall and con- 
nect with the upper carotid cervical glands. 

The nerves are derived from the glosso-pharyngeal, the 
fifth, and the sympathetic. A plexus formed by these 
nerves surrounds the tonsil and also give off branches. 

The Pharynx 

As usually designated, is the portion seen at the back 
of the mouth, but really includes the vault of the 
pharynx, and extends downward until opposite the fifth 
cervical vertebra and on a level with the cricoid cartilage, 
where it is continued as the esophagus. The pharynx may 
be considered as a musculo-membranous structure, four 
or five inches in length, and capable of more or less con- 
traction or expansion. The boundaries are, behind by the 
cervical vertebrae and coverings ; laterally the internal and 
external carotid arteries, internal jugular veins; vagus, 
glosso-pharyngeal, pneumogastric, and hypoglossal nerves. 
Anteriorly the boundary is interrupted by the structures 
which have already been described and also the larynx 
(the laryngo-pharynx), this portion being separated by the 
epiglottis. 

Marked morbid changes in any part of the pharynx may 
change the quality of the voice, as well as interfere with 
normal deglutition, and may affect the hearing either 
through faulty action of the Eustachian tubes or by exten- 
sion of the morbid state through the tubes to the tympanic 
cavities. 

The pharyngeal aponeurosis investing the pharyngeal 
structures consists of strong fibrous tissue. This aponeuro- 
sis is covered with mucous membrane which is continuous 



28 



Nose, Throat and Ear. 



with the nasai fossae, Eustachian tubes, mouth, larynx, and 
esophagus. In the upper portion the epithelium consists of 
the columnar ciliated form to the level of the nasal floor, 
below this it is squamous. Acinous glands are numerous 
throughout the membrane, while the lymphoid glands are 
grouped, especially in the upper part (pharyngeal tonsils), 
and surrounding the orifices of the Eustachian tubes. In 




ifojutffi 



Fig. 8. 



the latter location they are sometimes called Eustachian 
tonsils. 

Rosenmuller's fossa is opposite the tip of the petrous 
bone, one on each side of the pharyngeal wall, extending 
as a cul-de-sac. Each fossa is in relation behind with the 
recti muscles, in front with the Eustachian tubes, above with 
the sphenoid and petrous bones, and externally with the 
middle meningeal artery and otic ganglion. A thick, soft 
mucous membrane lines these fossae, which are supplied with 
glands and considerable lymphoid tissue. This tissue, as 



Larynx. 29 

already mentioned, constitutes the Eustachian tonsil. The 
character and function of this tissue is similar to that of the 
other tonsils. 

One of the principal functions of the pharynx in the 
existence of the individual, is its action in the deglutition of 
food after mastication. The pharynx is raised by the stylo- 
pharyngei to meet the descending bolus, which is then 
grasped and carried downward by the action of the three 
constrictor muscles of the pharynx, the inferior, middle, 
and superior constrictors. The inferior, or laryngo-pharyn- 
geus is the thickest of the three, and arises from the sides 
of the cricoid and thyroid cartilages, and then spreads back- 
wards and inwards, being inserted into the fibrous raphe on 
the posterior pharyngeal wall. The fibers of the inferior 
portion are horizontal in direction and are continuous with 
the fibers of the esophagus. The middle, or oropharyngeus, 
is smaller and fan shaped, and the origin is from the hyoid 
bone and stylo-hyoid ligament. The fibers diverge from 
their origin and are also inserted into the fibrous raphe. The 
superior, or naso-pharyngeus, constitutes the upper, or supe- 
rior, and is quadrilateral, thinner, and paler in color. Its 
origin is from the sphenoid and palate bones, and ligament- 
ous and tendinous tissue in this location. The insertion is 
also into the fibrous raphe, and also by a fibrous aponeurosis 
to the pharyngeal spine on the basilar process of the occip- 
ital bone. 

Larynx. 

This structure is located at the upper and fore part of 
the neck, being more or less prominent in the median line, 
and is easily palpated as it is comparatively close to the 
cutaneous surface. It is suspended from the hyoid bone, 
and is behind and below the base of the tongue. The 
mucous membrane is continuous with that of the pharynx 
and mouth, and passing downward, forms the tracheal and 
bronchial mucous membrane. 



3o 



Nose, Throat and Ear. 



Surface Landmarks. — The hyoid bone, the central prom- 
inence of the thyroid, pomum Adami, and the cricoid can 
always be discerned. At the level of the lower jaw and just 
below the mid-line, the body of the hyoid bone can be felt, 
and traced backward, ending in the greater cornua. 

Lower down in the median line there is a distinct de- 



JLesser Bom 



Iht beneath 2?yo- thyroid 
Membrane 



JjcUeral 
Thyro- hyoid 




CRICO THYROID 
{superficial port?) 



Crcco -thyroid 
Membrane 



Fig. 9. 

pression, corresponding to the central thyro-hyoid ligaments. 
This point usually designates the apex of the epiglottis. 

Below this is the prominence of the thyroid cartilage, 
varying in size and more marked in males, youth, and thin 
people. A large bursa is located in the subcutaneous cellu- 
lar tissue immediately in front of the anterior thyro-hyoid 
ligament and pomum Adami, which permits freedom of mo- 
tion of the larynx. Below the pomum the median ridge of 



Larynx. 3 1 

the thyroid cartilage can be distinctly determined. Still lower 
in the median line the depression corresponding to the crico- 
thyroid membrane and prominence of the cricoid cartilage 
can be felt. This is one of the most valuable landmarks. 

The upper border of the crico-thyroid membrane is on 
the level of the rima glottidis, the most narrow portion of 
the respiratory tract. The cricoid cartilage corresponds 
with the fifth cervical vertebra, when the head is in a normal 
position. It also marks the point of crossing the common 
carotid by the omo-hyoid, the lowest border of the larynx, 
and narrowest portion of the esophagus. The inferior 
laryngeal vessels and nerves have their entrance to the 
larynx at a point corresponding to the upper border. 

The lateral lobes of the thyroid gland can be detected at 
the sides of the thyroid and cricoid cartilages. The gland, 
adherent to the laryngeal structures and trachea, moves 
with the larynx in swallowing. 

In the median line and below the cricoid cartilage, one 
can feel the upper portion of the trachea. The upper two 
rings are close to the cutaneous surface, but those on a plane 
with the upper border of the sternum are one and one-half 
to two inches from the surface. Extreme extension of the 
head and neck will practically add another inch of trachea 
within reach, as well as making it more prominent. The 
second, third, and fourth tracheal rings are more or less 
curved by the thyroid isthmus. A large plexus of veins is 
always present in this region. 

The larynx is composed of rfine distinct parts, viz. ; four 
cartilages, the thyroid, cricoid, and two arytenoid ; one 
large fibro-cartilage, the epiglottis, and four smaller fibro- 
fcartilages, two of Wrisberg and two of Santorini. The 
latter are practically supplementary to the arytenoids. 
Luschka describes an inter-arytenoid cartilage as sometimes 
occurring, and oftener two pairs of small cartilages, anterior 
and posterior sesamoid. The thyroid, cricoid, and arytenoid 



32 Nose, Throat and Ear. 

cartilages frequently undergo ossification in the aged or in 
some diseases, but the fibro-cartilages are not thus affected. 
All the cartilages are connected by ligaments and articula- 
tions which permit of the various movements required of 
this organ. 

Thyroid Cartilage. — This is the largest of the cartilages, 
and the name means a shield. The thyroid contains and pro- 
tects the vocal cords. C. Ludwig terms it the stretching car- 
tilage, as the lever-like movements of the structure control 
the tension of the cords. It consists of two alse, or wings, 
united in front at a sharp angle by the lamina mediana car- 
tilaginis thyroidese. The vocal cords and the thyro-ary- 
tenoidei interni muscles are attached to this median lamina. 
The wings of the thyroid extending outwards and back- 
wards forms the lateral laryngeal walls. Their superior 
cornua, or horns, are connected with the hyoid.bone by the 
thyro-hyoid ligaments. The thyro-hyoid membrane, which 
extends from the cornua to the hyoid bone, unites these 
structures still more closely. 

The epiglottis is attached by its stalk to the inner sur- 
face of the thyroid cartilage in the receding angle and just 
below the median notch. From above the lower border 
posteriorly, and on each side of the median line, is the crico- 
thyroid membrane which joins the thyroid to the cricoid 
cartilage. The two inferior cornua of the thyroid articulate 
with the cricoid by capsular ligaments lined with synovial 
membrane. The vocal cords and the thyro-arytenoid mus- 
cles connect the thyroid and arytenoid cartilages. 

Cricoid Cartilage (a ring). — Ludwig terms this the foun- 
dation cartilage, as practically it sustains the laryngeal 
structure. The thyroid rests upon it through the articula- 
tions of the inferior cornua, and the arytenoid cartilages 
rotate upon it. The cricoid is smaller, but thicker and 
stronger than the thyroid, and is connected with the upper 
ring of the trachea by fibrous tissue. The anterior portion is 



Larynx. 



33 



narrow vertically, but posteriorly is broad and deep. The 
inferior rim is nearly horizontal, while the superior inclines 
upwards and backwards. The posterior portion, the lamina 
cartilaginis cricoidse is hexagonal in outline. In the median 
line at the back and internally an elevated ridge separates 



QrectierCbrnu 



Lesser Comu 




Capsu/a 



Fig. io. 



two slight depressions which receive the insertion of the 
posterior crico-arytenoid muscles, and serves for the at- 
tachment of the esophageal aponeurosis. Anteriorly the 
crico-thyroid membrane closes the space between the two 
cartilages. Two broad saddle-shaped articular surfaces for 
the bases of the arytenoid cartilages, are on the posterior 
and superior border. 
3 



34 



Nosk, Throat and Ear. 



Arytenoid Cartilages. — There are two of these. They 
are pyramidal in form, and each has three surfaces, a base 
and an apex. The posterior surface is triangular, smooth, 
and concave. The arytenoid muscle is attached to this sur- 



Vocal cord 
Tke Ventricle 



Cartilage 
ofWrtsberg 

Arytenoid 
CcLrtilage 



LATERAL 
CmCO-ARYTeNOlD 



Epiglottis 



Crico thyroid 
membrane 



Thyroid 
Cartilage 




THYRO EPIG-IOTTIDCAN 

Fasiculus 



THYRO ARYTENOIO 
m us-rfe 



Cricoid Cartilage 
in section, 



Fig. ii. 



face. The antero-external surface is rough and convex. 
The thyro-arytenoid muscle, and also the false vocal cords, 
are attached to this surface; the latter just above a depres- 
sion, the fossa triangularis. The internal surface is smooth, 



Larynx. 35 

narrow, and flattened, covered with mucous membrane, and 
(almost touches its fellow cartilage. 

The base is broad, concave antero-posteriorly, and 
smooth for articulation with the cricoid. Two processes 
project from the base', one postero-externally, the muscular 
process, which is short, rounded, and prominent, and to 
which the posterior and lateral crico-arytenoid muscles are 
attached. The second-vocal-process projects anteriorly, it 
is prominent, but more pointed and flattened. The true 
\ocal cord is attached to this process. Between the two 
processes is the base of the antero-external surface. The 
apex of each is pointed and curved upwards and inwards. 

Cornicula Laryngis (cartilages of Santorini). — These 
are above the upper pointed ends of the arytenoids and 
located in the substance of the ary-epiglottic folds. They 
are conical, small, and flexile, being composed of yellow 
fibro-cartilage. They probably prevent pressure of the epi- 
glottis against the apices of the arytenoid cartilages during 
deglutition. 

Cuneiform Cartilages (Cartilages of Wrisberg). — These 
are two small wedge-shaped cartilages contained within 
the ary-epiglottic fold and in front of the arytenoids. 

Posterior Sesamoid Cartilages. — These are not always 
present. Luschka describes them as very small, oblong 
bodies, attached by delicate ligaments to the Santorini car- 
tilages above and the arytenoids below. They are located 
near the lateral margin of the 'arytenoids. 

Anterior Sesamoid Cartilages. — These are frequently 
present. Each is about the size of a pin-head, and embedded 
in the anterior part of the vocal cords. A tough tissue 
unites them to the thyroid. 

Inter-arytenoid Cartilage. — This is very infrequent, but 
when it does occur it will be found as a small body be- 
tween the arytenoids. 

Epiglottis. — This is a thin leaf-like lamella of yellow 



36 



Nose, Throat and Ear. 



fibro-cartilage, located between the base of the tongue and 
the superior opening of the larynx. The upper free ex- 
tremity is broad and rounded ; its stalk, or attached end, is 
long and narrow, and is firmly connected to the thyroid 



TongiA.e 



fold 



Over Carktiaxfi 
brtiecea. 

Jry- epiglottic fold 

Cartilage ofWrisberQ 
exposed 



XesserTwrn 
cfTkyroic? 



Cart'dago triticecc 

exposed 

Over Cartilage of 
Wrisbe-rg. 




Over A ryferwixl 
(XwtvlcLge 



Crico -thyroid Zip 

Fig. 12. 



cartilage at the receding angle and just below the median 
notch by the thyro-epiglottic ligament. It is also attached to 
the posterior surface of the hyoid bone by the hyo-epiglottic 
ligament which forms part of the central thyro-hyoid liga- 
ment. 

The body of the epiglottis is retained in position by five 



Larynx. 37 

bands, three of which pass forwards to the base of the 
tongue, and two backwards to the arytenoid cartilages. The 
central ligament in front consists of a fold of mucous mem- 
brane reinforced by fibro-elastic tissue, extending from the 
center of the body to the base of the tongue, where it ex- 
pands and merges into the lingual fibrous covering. 

The central glosso-epiglottic ligament unites with a 
strong white fibrous membrane which covers the entire front 
surface of the epiglottis. The membrane is attached to the 
entire length of the hyoid bone, and extends from the sides 
of the epiglottis in two conspicuous folds, spreads laterally 
and lines the tonsillar fossae. Lennox Browne designates the 
membrane as the epiglottic membrane, and the lateral folds 
as amygdalo-epiglottic ligaments. 

The so-called lateral °dosso-epiglottic ligaments exist 
only when the mouth is open and the tongue considerably 
extended. They consist simply of two folds of mucous 
membrane extending from the sides of the tongue to the 
epiglottis. 

The posterior, or aryteno-epiglottidean folds are two 
thick bands consisting of muscle and mucous membrane, ex- 
tending backwards from the recurved sides of the epiglottis 
to the arytenoid cartilages. They separate the cavity of 
the larynx from the hyoid fossae. 

The hyo-epiglottic ligament unites the epiglottis with 
the basi-hyal. 

The epiglottis as a body is curved upon itself from above 
downwards as well as from side to side. The lingual sur- 
face is concave from above downwards and convex from 
side to side. The superior margin is curved forward over 
the base of the tongue. The laryngeal surface is concave 
from side to side, and concavo-convex from above down- 
wards. The degree of curvature varies considerably. A 
more or less well marked eminence is found on the laryngeal 
surface at the. junction of the stalk and blade. 



38 Nose, Throat and Ear. 

The interior of the larynx is divided into three divisions ; 
•the supraglottic is the upper and largest, and is the space 
above the ventricular bands. It is heart-shaped, the broad- 
est part being in front, corresponding with the line of the 
epiglottis. The lateral walls are formed by the folds con- 
necting the epiglottis with the arytenoid cartilages. 

The glottic, or second space, includes the ventricular 
bands, vocal cords, and ventricles of Morgagni. 

Ventricular bands, sometimes called the false vocal 
cords, are two folds of mucous tissue containing a little 
fibrous tissue, the superior thyro-arytenoid ligaments. In 
front they are attached to the thyroid cartilage, and behind 
to the anterior surface of the arytenoids. They may be 
closely approximated. The closure occurs in the act of 
swallowing, as well as some other muscular efforts, as 
;coughing, straining, etc. 

Vocal Cords. — These consist of bands of pure yellow, 
elastic tissue, the inferior thyro-arytenoid ligaments. The 
cords are attached to and continuous with the upper free 
margin of the crico-thyroid membrane. As the cords and 
ci*ico-thyroid membrane are practically continuous struc- 
tures, it will be necessary to describe the latter first. 

Crico-thyroid Membrane. — This is a thin fibro-elastic 
tissue attached to the upper and inner margin of the anterior 
two-thirds of the circoid cartilage. It passes upwards, and 
converging behind the thyroid cartilage, is attached to the 
angle of the thyroid cartilage on its inner surface about a 
quarter of an inch from the inferior border ; behind it is 
attached to the vocal processes of the arytenoid cartilages, 
and part of the external border of their base. The upper 
free margin of the membrane, reinforced by antero-posterior 
bands of yellow elastic tissue, and placed as a movable band, 
comprises the inferior thyro-arytenoid ligaments or true 
vocal cords. 

The inner surface of the membrane is smooth and cov- 



lyARYNX. 39 

ered by an adherent mucous membrane. The thyroary- 
tenoid muscles also cover this surface. Fibers of muscular 
tissue pass to, and are attached to the voca*l cords and upper 
portion of the thyro-hyoid membrane. These fibers are 
important in influencing the vibration and position of the 
vocal cords. 

The length of each cord when at rest is approximately 
three-fourths of an inch in the adult male, and half an inch 
in the female. A section of the cord shows a triangular 
form, the acute angle or apex being directed toward the 
median line. The upper and lower surfaces are not per- 
fectly free, only the edges being so. The vocal cords are 
really a fold of the crico-thyroid membrane. In color the 
cords are white, this being most pronounced in the female. 
The yellow elastic tissue of the cords is necessary for pre- 
serving tension without muscular effort, and wrinkling when 
relaxation occurs. 

Ventricles of M or gagni.— These are the two spaces be- 
•tween the ventricular bands and vocal cords, and constitute 
the inferior openings of the saccules. The ventricles are 
elliptical in form, and vary considerably in size. 

Sacculus Laryngis. — In man this is a comparatively un- 
important structure. The sacculi are lined with muciparous 
glands and a considerable amount of lymphoid tissue, and 
extend down to the lateral attachments of the vocal cords. 

The third, or infra-glottic space, comprises the portion 
of the larynx from the inferior surface of the vocal cords 
•to the inferior border of the cricoid cartilage. 

Physiologically and clinically the second, or middle divi- 
sion, is the most important. Not only phonation is repre- 
sented at this point, but the vocal cords perform a special 
action in respiration. This opening is termed the glottis or 
rima glottidis. In repose the shape is more or less elliptical, 
being nearly an inch long in the male, and two or three lines 
less in the female. The shape of the rima glottidis varies 



40 Nose, Throat and Ear. 

according to requirements ; in full inspiration it is irregu- 
larly triangular, the apex forward at the thyroid angle, at 
the origin of the vocal cords — anterior commissure of the 
vocal cords — the two posterior angles being at the arytenoid 
cartilages, the insertion of the cords ; the base is more or 
less curved, and is formed by the space between the carti- 
lages — inter-arytenoid space, or posterior commissure of 
the vocal cords. In the production of high notes, as the 
upper register in singing the cords are almost closed. All 
variations are found between these two extremes. 

The vocal cords are controlled by certain muscles, the 
intrinsic are usually grouped as follows : 

ACTION. 

i. Narrowing the vestibule. 

Thyro-ary-epiglottidei { ThyrTepSotlidei ] K ^ ira ' 



Arytenoideus ) 

2. Governing the shape of the Rima Glottidis. 

Thyro-arytenoidei ~) 

ex- and interni ! ~. , , , . . 

~ ■ ■ -, • > Close true glottis AT 1 , 

Cnco-arytenoidei [ I ° a 

laterales J respiratory. 

Arytenoideus . . . closes cartilaginous 

glottis 
Crico-arytenoidei postici^open glottis — Respirator}-. 
3. Governing the pitch of the voice. 

Crico-thyroidei Tense the vocal cords. 

f Shorten, relax and bring in 

a^, -j . . . • ! apposition various sections 

rhyro-arytenoidei interni < Z\ x . , , . 

of the vocal cords and act 



as local extensors. 

(Browne.) 

Crico-arytenoidei Postici. — These are the abductors of 
the vocal cords, being active on inspiration. They consist 
of two triangular muscles, the bases having their origin on 



tyARYNX. 41 

the posterior surface of the cricoid cartilage, they converge 
upwards and outwards until they reach the processus mus- 
culares of the arytenoids. The action of drawing these back- 
wards and inwards causes the processus vocales to move 
outwards, opening the rima glottidis. This motion varies 
according to individual needs. 

Crico-arytenoidei Later ales. — These muscles have their 
origin along the upper border and outer surface of the sides 
of the cricoid cartilage. They pass obliquely upwards and 
backwards, and are attached to the outer angles of the bases 
of the arytenoid cartilages and adjacent parts of the anterior 
surfaces in front of the posterior crico-arytenoid. The 
upper fibers are occasionally mingled with the fibers of the 
thyroarytenoids. 

Arytenoideus. — This muscle is square and is attached to 
the posterior concave surface of the arytenoid cartilages. 
The action is that of an aid to the crico-arytenoidei lat- 
erales in closing the glottis. The opinion now held by many 
is that this muscle is a continuation of the thyro-arytenoi- 
deus. When the arytenoideus acts first, the rima glottidis 
assumes momentarily a rhomboid shape ; when the crico- 
arytenoidei laterales act first, the vocal cords are approxi- 
mated and the space between the arytenoid cartilages re- 
mains open. 

Thyro-arytenoidei. — These two muscles are broad, flat, 
and fan-shaped, parallel with but external to the vocal 
cords, being partially inserted into them. The anterior at- 
tachment of the muscles is to the internal surface of the 
thyroid cartilage, the inferior fibers lying close to the angle 
of the thyroid. Each muscle is composed of two distinct 
divisions. 

The upper is thin, inserted high up on the anterior sur- 
face and outer border of the arytenoid cartilage, partially 
encircling the laryngeal pouch, some of the fibers pass round 
the outer border of the arytenoid cartilage, and intermingle 



42 Nose, Throat and Kar. 

with the transverse fibers of the arytenoideus, and under- 
neath the oblique .fibers of the ary-epiglottideus. 

The lower division is a thick, well defined fleshy bundle, 
and is reinforced by a. few fibers from the outer surface of 
of the crico-thyroid membrane. It extends backwards and 
is inserted into the anterior projection, or vocal process of 
the arytenoid cartilage, external and close to the vocal cord, 
also to the adjacent surface and close to the insertion of the 
corresponding lateral crico-arytenoid muscle. 

Occasionally there is a small third division — the thyro- 
arytenoideus of Soemmering — having its origin from be- 
hind the thyroid notch, close to the median line and passing 
internally to the pouch, to be inserted into the antero-ex- 
ternal surface of the arytenoid cartilage near its base. 

Ary-epiglottici. — These are two thin, flat muscles, hav- 
ing their origin from the outer and posterior border of the 
apex of the corresponding arytenoid cartilage, and pass up- 
wards and over to the opposite side through the ary-epi- 
glottic folds to the epiglottis. These muscles are called the 
constrictores vestibuli laryngis. Their action is to approxi- 
mate the tips of the arytenoid cartilages and to cause the 
edges of the epiglottis to turn inwards during the act of 
swallowing, and probably also in phonation. 

Crico-thyroidei. — Each muscle presents a fan-like shape 
and consists of two divisions. The lower ends of each sec- 
tion are pointed and have their origin from the antero-lat- 
eral portions of the cricoid cartilage. The fibers diverge as 
they pass obliquely upwards and backwards, and are in- 
serted into the inferior border of the thyroid cartilage, the 
anterior borders of the lower cornua and into the internal 
and external surfaces near the margin. The function of 
these muscles is to draw the thyroid forwards and down- 
wards, tilt the cricoid and arytenoid cartilages backwards, 
thus producing tension on the vocal cords. 

Arteries. — The laryngeal blood supply is through 



Larynx. 43 

branches from the superior and inferior thyroid, the former 
being a branch of the external carotid, the latter of the 
thyroid axis from the subclavian. Small branches are de- 
rived from the lingual and ascending pharyngeal. 

The superior laryngeal artery from the upper thyroid 
passes upwards, inwards,, and downwards, accompanying 
the superior laryngeal nerve penetrating the thyro-hyqid 
membrane to the interior of the larynx. Inside the larynx 
the artery lies between the thyroid cartilage and thyro-afy- 
tenoid muscles, and distributes branches to the intralaryn- 
geal structures, uniting above with twigs from the lingual 
and tonsillar, and below with twigs from the superior laryn- 
geal, a branch of the inferior thyroid. The inferior laryn- 
geal artery varies in size and ascends along the back of the 
trachea and larynx, being distributed to the small muscles 
and mucous membrane in the region of the arytenoid car- 
tilages connecting with the superior laryngeal. 

Veins. — The laryngeal veins correspond with the arteries. 
The upper laryngeal veins, penetrating the thyro-hyoid 
membrane, empty into the internal jugular, lower facial, or 
the superior thyroid. 

Lymphatics. — The laryngeal lymphatics join the cervical 
glands. 

Nerves. — The superior, and recurrent or inferior laryn- 
geal, are branches from the pneumogastric, the motor being 
of spinal accessory origin. Filaments from the sympathetic 
accompany the arteries. Plexuses are formed by the junc- 
tion of quite large branches. Prominent anastomoses occur 
at the back of the arytenoid cartilages beneath the pharyn- 
geal mucous membrane, also at the sides of the larynx be- 
tween the wings of the thyroid cartilages and the thyro- 
arytenoidei. 

The superior laryngeal supplies the laryngeal mucous 
membrane and the crico-thyroid muscles. The recurrent 



44 Nose, Throat and Ear. 

laryngeal supplies the rest of the muscles. The arytenoicleus 
is supplied by both nerves. 

Minute Anatomy. 
The laryngeal mucous membrane is similar to the 
pharyngeal in being composed of epithelium, tunica propria, 
and submucosa. Stratified squamous epithelium covers the 
epiglottis and the inner surface of the larynx as far as the 
lower edge of the false vocal cords. Below this the epi- 
thelium is of the stratified ciliated columnar variety, except- 
ing over the true vocal cords where it is again of the strati- 
lied squamous type. The tunica propria of the larynx con- 
sists of fibrous connective tissue with a network of elastic 
fibers. Longitudinal bundles of elastic tissue, with some 
fibrous tissue, constitute the true vocal cords, which are 
covered with stratified squamous epithelium, reinforced 
externally by fasciculi from the thyro-arytenoideus muscle. 
The thyroid, cricoid, and greater part of the arytenoid car- 
tilages are composed mostly of hyaline cartilage. The epi- 
glottis, apex of the processus vocales of the arytenoid car- 
tilages, the cartilages of Wrisberg and Santorini are of the 
yellow elastic variety. The fibrous connective tissue of the 
external surface of the larynx connects the perichondrium 
with the surrounding tissues, muscular attachment being by 
tendinous tissue continuous with the cartilaginous invest- 
ment. 



CHAPTER II. 
EAR. 

Physiologically the ear may be divided into two parts, 
the conducting and receptive portions, but anatomically 
three divisions are made, (i) External (auricle or pinna, 
and external auditory canal). (2) Middle (tympanic cav- 
ity, membrana tympani, ossicles, Eustachian tube, and mas- 



Fossa <?/> 




vsstv of Helix: 



x-b^iicdilon/ 
Meatus \ 



Fig. 13. 

toid process). These two anatomical divisions constitute 
the physiological first or conducting apparatus. (3) The 
inner or internal (labyrinth) consisting of the vestibulum, 
the three semi-circular canals and cochlea, the latter being 
the receptacle for the expansion of the auditory nerve. This 
constitutes the second physiological division, or receptive 
portion. 

45 



4.6 Nosk, Throat and Ear. 

The auricle, or pinna, is ovoid or pyriform. the larger 
end being above. The external surface is irregularly con- 
cave, and directed a little forward. A number of irregular- 
ities, the effect of the foldings of the fibro-cartilaginous 
frame-work are noticeable. The outer rim is the helix. 
Parallel and in front of the helix is another curve, the 
antihelix. The latter divides above and encloses a triangular 
depression, the fossa of the antihelix. The narrow, depres- 
sion between the helix and antihelix is the fossa of the helix. 
The antihelix curves round a deep depression, the concha, 
which is partially divided by the beginning of the helix. In 
front of the concha, and extending backwards over the 
meatus, is a prominent structure, the tragus. A little below 
and posteriorly from the tragus, and separated from it by 
a deep notch (incisura intertragica), is a small prominence, 
the antitragus. Below is the lobule. 

The cartilage of the auricle is one piece, but is not con- 
tinuous throughout. It is lacking in the lobule and practi- 
cally so between the tragus and helix, the space being filled 
by dense fibrous tissue. At the front part of the auricle 
where *the helix curves upward, the cartilage forms a small 
projection, the process of the helix. Several fissures are 
also present in various parts of the cartilage. The walls 
of the auricle gradually converge and form the cartilag- 
inous meatus. 

Cartilaginous Meatus. — The shape of the canal is oval. 
The inner extremity of the cartilaginous portion is united 
to the bony canal by firm bands of connective tissue. Supe- 
liorly and posteriorly the cartilaginous structure is lacking,, 
and becomes more marked until at the junction with the 
bony portion, the inferior wall only contains cartilage, this 
extending a short distance along the floor of the bony canal. 

Firm connective tissue fills the space in the cartilaginous 
portion where cartilage is lacking. This tissue is continu- 
ous with the periosteum of the corresponding part of the 



Ear. 



47 



bony canal. Two verticle fissures are present in the anterior 
cartilaginous wall. These fissures, incisures of Santorini, 
[ire filled with connective tissue. The larger is at the base 
of the tragus, the second deeper in the canal. Sometimes a 
third fissure, still deeper, is present. These fissures permit 
of some mobility of the cartilaginous portion, and also on 
account of less resistance at these points, sometimes allow of 
spontaneous rupture into the auditory canal in deep ab- 
scesses of the parotid gland. Surgically they are important, 



Tegment. 
tympani 

Stapes 




Incus 

,_-/« Fallopi 
-Fenestra ovatis 



rvr-Canalis Fallopiac 
— Fenesti 
L-Umbo 



tet* <* "romontortum, 
a — Memhr. tympani 

\ 

Ca-vwrn. tympani 
tens, ttpp. 
membr. tymp. 



Transverse vertical section through Right Ear. 

Fig. 14. 

as they allow the tinning forward of the auricle and fibro- 
cartilaginous canal after the posterior, inferior, and superior 
attachments have been loosened. 

Bony Canal. — A consideration of the development of the 
temporal bone is necessary. This part of the skull is devel- 
oped from four centers; the squamous, petromastoid, audi- 
tory or tympanic and stylomastoid. 

At birth the osseous canal is lacking, fibrous tissue taking 
its place. At the inner end this terminates in the auditory 



48 'Nose, Throat and Ear. 

process, or tympanic ring. This consists of a thin bony 
strip, annulus' tympanicus, oval in shape and about an eighth 
of its circumference being lacking. The concave margin of 
the ring is grooved, sulcus tympani, for the insertion of the 
membrana tympani. 

The squamous portion of the temporal bone is developed 
from a single center. In early fetal life it presents a flat, 
bony -scale, with a ridge upon the outer surface, which later 
forms the zygomatic process. Below the root of the zygoma 
is a shallow depression, the glenoid fossa. Behind this the 



4$W - : ^h 

ww -,/.'. Incut JP*Jb 




• Membrana %\ 

tympani S^^>' 

Membrana Tympani and Ossicula of new Lorn child from 
inner side 

Fig. 15. 

bony plate divides into two lamelbe, the inner projecting 
almost horizontally inward, later forms the roof of the 
tympanum and mastoid antrum. The outer lamella extends 
downward and a little inward and presents a deep notch 
upon the inferior border. The annulus tympanicus joins 
the latter lamella at this notch, which by the manner of 
attachment completes the circle. This completed circle 
gives attachment to the inner end of the fibrous canal. As 
the fetus develops, this fibrous tissue is replaced by bony 
tissue, and the annulus tympanicus becomes a bony groove 
through ossification outwards, 



Ear. 49 

In the adult the deep groove formed by the outward 
growth of the tympanic ring is called the auditory process. 
In front it is separated from the squamous portion of the 
temporal bone by the Glaserian fissure. Posteriorly the audi- 
tory process helps in forming the mastoid squamous suture, 
its postero-superior point being the spinum supra-meatum. 
The outer plate of the squama, which completes the outline 
oi the bony meatus, grows almost directly outward horizon- 
tally, and almost at right angles to the part of the temporal 
bone above the zygomatic process during development. 

The third portion of the temporal bone, the petro-mas- 
toid, is an oblique triangular pyramid, the apex forward and 
inward, the base closing the space between the free margin 
of the squamous plate of the temporal bone and the posterior 
crus of the annulus tympanicus. 

The junction of the mastoid portion to the external 
squamous lamella forms the mastoid squamous suture. The 
petrous portion uniting with the inner lamella, forms the 
petro-squamous suture. 

Tympanic Cavity. — This is a chamber more or less sur- 
rounded by bony walls. The inner wall is formed by the 
external surface of the petrous portion of the temporal bone. 
It is marked by a rounded elevation, the promontory, cover- 
ing the first turn of the cochlea. Behind and a little below 
the promontory, is the niche of the round window, into 
which the fenestra rotunda opens. Above, in the upper and 
posterior part of the inner wall, is an oval fossa, the pelvis 
ovalis, at the bottom of- which is the oval window. The 
posterior wall of the pelvis ovalis is abrupt, but the anterior 
wall gradually slopes forwards, merging into the surface of 
the promontory. The inferior wall is longer and steeper 
than the superior. Above the oval window a distinct bony 
arch is formed by the prominent outer wall of the aqueductus 
Fallopii protruding into the tympanic cavity. This canal 
transmits the facial nerve. The outer wall of this canal is 



5o 



Nose, Throat and Ear. 



sometimes defective and the facial nerve is then uncovered 
at this point. It is important to remember this in treating 
suppurative diseases of the middle ear, as often paralysis 
results from too energetic measures. 

Just above the aqueductus Fallopii is a smaller ridge, 
caused by the horizontal semi-circular canal. Posteriorly 
to the pelvis ovalis, and where the inner and posterior walls 
of the tympanum join, is a small bony pyramid. The tendon 




■mastoid. 

H. rACIMJS 



Inner Wall of Tympanum, x 3. 

Fig. 16. 



of the stapedius muscle passes through its apex. The inner 
wall of the tympanum is more nearly in the median antero- 
posterior vertical plane of the body than the plane of the 
tympanic ring; for this reason the cavity is broader above 
and behind than below and in front. In front of the prom- 
ontory the inner wall is smooth and merges into the 
tympanic orifice of the Eustachian tube. 

The Anterior Wall. — The Eustachian tube opens at 
about the center of the anterior wall. The canal for the 
tendon of the tensor tyrnpani muscle is above the Eustachian 



Ear. 5 1 

opening, being separated by a thin, bony plate, the processus 
cochleariformis. A thin plate of bone separates the ante- 
rior wall from the internal carotid artery. 

The floor of the cavity is bony, the structure sometimes 
being fairly compact bone, but often cancellus. The floor 
is considerably below the lower border of the tympanic ring, 
and is close to the jugular fossa. Openings sometimes ex- 
ist between the floor and the fossa, and the bulb of the in- 
ternal jugular vein may be injured by instrumental manipu- 
lation. 

The posterior wall presents, besides the pyramid, the 

\Emtnence for superior 
Vscmicircitlar Cbuictl- 

r sthrnus7u£& 



AqueRcUictusTcdlo, 

STAPEDIUS 




EustczdiAarvTube 



Fig. 17. 

opening into the mastoid antrum. This opening is directly 
above the pyramid. 

The external wall is formed principally by the mem- 
brana tympani, the inner surface of the tympanic ring, and 
above, the inner margin of the external plate of the squama 
and the angle formed by the inner and outer plates also 
enter into the formation. 

The vault of the tympanic cavity, or epitympanic space, 
is considerably above the plane of the superior wall of the 
external auditory canal. The portion below this plane is 
the atrium. 

Vault of the Tympanum. — This is more or less pyramidal 
in shape, the apex being at the angle between the plates 



52 



Nose, Throat and Ear. 



of the squama. These, with the adjoining parts of the 
petrous bone and petro-squamous suture, form two bony 
surfaces of the pyramid. The remaining surfaces and base 
are incomplete, the openings into the mastoid behind and 
the tympanum below corresponding to these two portions. 
Normally the base is partially rilled in by the ossicles and 
their ligaments, as well as by reduplications of the tympanic 



Fenestra n?i 




rtadri*' 1 



Tub* 



FlG. i 8. Vertical section through tympanum. The dotted oval 
shows the relation of the memhrana tympani to the tympanum. 

mucous membrane, partially dividing the tympanum into 
two parts. 

OSSICUS. — These are three in number; malleus, incus, 
and stapes. These bones aid in transmitting and modifying" 
the vibrations of sound by imparting to the labyrinthine 
fluid increased intensity, but the waves are diminished in 
amplitude. 



Ear. 53 

The Malleus. — This is the largest of the three bones, and 
consists of a head, neck, and shaft, or manubrium. The 
manubrium is classed by some as a process, the same a.s the 
processus gracilis and processus brevis. 

The head is irregularly oval, presenting posteriorly the 
surface for articulation with the incus, and anteriorly a 
groove for the attachment of the anterior ligament. 

The neck is a narrow constricted part joining the head 
and handle at an obtuse angle. 

The manubrium, also called the handle, shaft, or long 
process, is flattened from within outward, and gradually 
tapers from about the neck to the tip, which occasionally 
projects slightly forwards, forming a hook. From the 
junction of the handle with the neck, is the short process, 
processus brevis, a conical bony projection, directed for- 
ward and outward and in contact with the membrana tym- 
pani. The external border of the handle furnishes attach- 
ment to the tympanic membrane, while the inner border is 
toward the inner wall. The anterior and posterior surfaces 
are comparatively broad. Projecting from the anterior sur- 
face just below the short process and passing forward and 
outward to the Glaserian fissure, is the long delicate pro- 
cessus gracilis or folianus, which is often embedded in 
the fibers of the anterior ligament in adults. 

The external surface of the neck of the malleus is 
roughened, giving attachment for the external ligament. 
The anterior surface of the neck and contiguous portion of 
the head are grooved for the insertion of the anterior liga- 
ment. 

The Incus. — This bone consists of a body and two proc- 
esses. The body is somewhat quadrilateral, but the height 
is nearly double the width. The anterior surface presents a 
concavo-convex facet for articulation with the malleus. This 
surface is covered with cartilage and lined with synovial 
membrane. 



54 Nose, Throat and Ear. 

The two processes form nearly a right angle with each 
other. 

The short, or horizontal, process, conical in form, is 
really a continnation of the body, and extends backwards, 
the apex resting in a depression — sella incudis — in the pos- 
terior tympanic wall immediately below the opening into 
the mastoid, having a ligamentous attachment. 

The long or descending process is a tapering, slender 
bone, passing nearly vertically downward from the antero- 
inferior angle of the body. The lower portion bends in- 
ward, the rounded tip being toward the internal wall. This 




staged. 

Ossicula. x 3. 
Fig. 19. 

tip is the lenticular process and articulates with the head of 
the stapes. 

The Stapes. — This, the third of the series, is a stirrup- 
shaped bone, consisting of a head, two branches — crura — 
and base. The head is rounded and presents on the external 
surface a depression for articulation with the lenticular proc- 
ess of the incus. Just below the, head is a constricted part 
of the bone — the neck — the crura diverging from it. The 
posterior crus is the most curved and longest. The crura 
terminate in a flattened, oval-shaped bone, the base or foot- 
plate, which is fixed to the margin of the fenestra ovalis by 
ligaments. 



Bar.. 55 

The stapes lies almost entirely within the pevis ovalis, 
so is well shielded from injury when instruments are used 
through the external auditory canal. The position of the 
hone is oblique, and is nearer the inferior and posterior walls 
of the fossa than the anterior and superior. As the posterior 
wall is nearly vertical, the posterior crus of the stapes is in 
close relation to it, and adhesions between these two struc- 
tures are common. 

Ligaments of the Ossicles. 

Ligaments of the Malleus. — These consist of the anterior, 
external, posterior, and superior or suspensory. 

The anterior is the strongest. Its origin is from the 
spina tympanica major and wails of the Glaserian fissure. 
The ligament passes outward, upward, and backward, to 
be inserted into the anterior surface of the neck and de- 
pression on the anterior surface of the head of the malleus. 

The External Ligament. — This is rather fan-shaped. Its 
origin is from the external roughened surface of the neck 
of the bone, the fibers diverging and being inserted into the 
free margin of the inner extremity of the superior wall 
formed by the external plate of the squama. Helmholtz 
describes the posterior fibers as a distinct band, the posterior 
ligament. 

This band, with the anterior ligament comprises the 
axis band of the malleus. 

The Superior Ligament. — This is a rounded delicate 
band of fibrous tissue passing from the tegmen tympani 
downward to the head of the malleus. 

Ligaments of the Incus. — The incus is attached to the 
tympanic wall by a single fibrous band, the posterior liga- 
ment. At its origin from near the tip of the lateral surfaces 
of the short process, it is a dense structure, but the fibers 
rapidly diverge, and divide into two bundles, which are in- 
serted into a broad area on the posterior tympanic wall. 



56 Nose, Throat and Ear. 

Ligaments of the Stapes. — The base of the ossicle is 
held in position in the oval window by means of the annular 
or stapedio-vestibular ligament. The borders and vestibular 
surface of the base and periphery of the oval window are 
covered with hyaline cartilage. The annular ligament is de- 
veloped from the perichondrium. 

Inter ossicular Ligaments. — The articular surfaces- of 
the ossicles are covered with cartilage. The malleus and 
incus are united by a loose capsular ligament. 

The Eustachian Tube — This might be called an acces- 
sory portion of the middle ear. The function of this tube is 
for ventilation of the middle ear and to equalize the pressure 
between the tympanic cavity and the external atmosphere. 
The tube consists ot two portions, the bony or tympanic, 
and cartilaginous or pharyngeal. The junction of these two 
is called the isthmus. 

The bony portion is about half an inch in length, extend- 
ing from a comparatively wide opening just above the mid- 
dle of the internal tympanic wall, and rapidly narrowing as 
it passes downward, forward, and inward through the 
petrous portion of the temporal bone to the isthmus, where 
the diameter is from one-twenty-fifth to one-twelfth of an 
inch. The bony portion of the canal is somewhat triangular 
in shape, the vertical line being about double the horizontal. 
Fibrous tissue joins the bony and cartilaginous portions of 
the tube at an obtuse angle. 

The cartilaginous portion of the tube is about an inch 
in length. From the isthmus it extends downward to the 
pharynx increasing in width until at the orifice it is from 
cne-eighth to one-fifth inch in diameter, the vertical still 
being the greatest. This portion of the canal is fibrocartilag- 
inous. A plate of cartilage, the upper portion of which is 
curved forward and then downward, forms the posterior 
walL A transverse section is hook-shaped. The space be- 
tween the end of the hook and the lower edge of the cartilag- 



Ear. 



57 



inous plate is filled with fibrous and muscular tissue. The 
lumen of the cartilaginous portion is slitlike. The mem- 
branous tube is connected to the inner end of the bony canal 
the posterior plate of cartilage uniting with an extension of 
the corresponding "bony wall. 

Membrana Tympani. — Principally for the protection of 



Incus* 




Itfanubruwv 
TynipcinicMembrane 



Fig. 20. Eustachian Tube and Tympanum. (Right Ear.) 



the intra- tympanic structures, and secondarily for the pur- 
pose of assisting in the transmission of sound waves, a par- 
tition is placed, dividing the external auditory parts from 
the middle ear. This is the membrana tympani. 

This is a fibrous membrane and forms the greater part 
of the outer wall of the tympanic cavity. It is located at 



58 Nose, Throat and Ear. 

the inner extremity of the bony portion of the auditory 
canal, and at birth is nearly horizontal, gradually assum- 
ing a more perpendicular position until adult life. The 
normal position of the membrane in the adult is obliquely 
with the long axis of the bony canal, thus making the ante- 
rior and inferior auditory canal walls the longest. 

The membrana tympani is attached at its margin to z 
groove, sulcus tympanicus, in the bony canal. The fibrous 
tissue is somewhat thickened at the point of attachment, 
the annulus tendinosus, or cartilaginous ring. From this 
ring some fibers pass outward to the periosteum of the bony 




FlG. 21. External Surface of Right Membrana 
Tympani. x 3^. 

canal and others go in the opposite direction, mingling with 
/the periosteum of the tympanum. 

The manubrium is attached to the substantia propria by 
means of a thin cartilaginous lamella, which passes along its 
outer border from the processus brevis to. the umbo, the 
fibers of the membrane being continuous with the perichon- 
drium of the cartilaginous lamella. The circular and ra- 
diating fibers are attached directly to the tip of the manu- 
brium. The superior border of the lamina propria joins the 
anterior and posterior extremities of the annulus tympan- 
icus, forming a tense fibrous band, which is divided into 
two parts by the short process of the malleus. The pos j 



Bar. 



59 



terior fold is the sharply defined superior margin of the 
membrane extending from the short process to the posterior 
extremity of the annulus. Shorter and less distinct is the 
anterior fold. 

The fibrous septum is lacking where the curved outline 
of the annulus is completed by the auditory plate of the tem- 
p-oral bone. This space constitutes the Rivinian segment, 
and is closed by the cutaneous lining of the external audi- 
tory canal. As compared with the rest of the membrana 
tympani, this portion is loose, and is called the membrana 







■'•'■>^y : i*f Short process 
m F ani ^^gp^ 

Handle of Malleus 



Right Membrana Tympani. External view. 

Fig. 22. 



flaccida, or Shrapnell's membrane. The fibrous layer is 
especially well developed along the anterior and posterior 
borders, which cause it to be somewhat triangular in shape. 
These distinct fibrous bands are the fibers of Prussak, and 
pass from the two extremities of the Rivinian segment to 
the base of the short process and continuing along the 
manubrium are merged into the external layer of the mem- 
brana propria. 

The normal membrane is somewhat oval in outline, and 
is drawn inward, the most concave point being at the umbo, 
where the tip of the manubrium is attached directly to the 



6o Nose, Throat and Kar. 

membrana propria. The anterior and inferior segments 
bulge outward somewhat, so that although the membrane in 
its entirety is concave, it is convex from the center to the 
periphery. 

The Muscles. — The muscular structures of the conduct- 
ing portion are the extrinsic, connecting the auricle to the 
skull ; intrinsic, comprising those of the auricle and canal ; 
the intratympanic, and those of the Eustachian tube. 

Posteriorly the auricle is connected to the skull by the 
mastoid fascia, and anteriorly by the temporal fascia. 

Extrinsic Muscles. — There are three, which in man are 
usually rudimentary so far as' action is concerned. The 
retrahens aurem, attollens aurem, and attrahens aurem. 

The retrahens has its origin from the' mastoid region by 
short aponeurotic fibers, and is inserted into the auricular 
cartilage at the posterior and inferior portion. 

The attrahens has its origin from the lower edge of the 
epicranial aponeurosis and converges to be inserted into 
the cranial surface of the spine of the helix. 

The attollens has its origin from the aponeurosis of the 
occipito-frontalis, and converges to the insertion at the upper 
part of the cranial surface of the auricle. 

The Intrinsic Muscles. — These are practically rudimen- 
tary muscles in man, consisting of incompletely developed 
muscular fiber bundles arranged between the cartilaginous 
processes of the auricle. 

The Intratympanic Muscles. — Two muscles comprise 
this group, the tensor tympani and stapedius. 

The Tensor Tympani. — The origin of this muscle is 
from the upper wall of the cartilaginous Eustachian tube 
and also the bony walls. It enters the tympanum through a 
bony canal just above the tympanic opening of the Eusta- 
chian tube, being separated from the latter by the processus 
cochleariformis. This process in the tympanum is pyra- 
midal and is sometimes called the anterior pyramid. The 



Ear. 6 i 

tendon twists almost at a right angle around this process, 
passes across the tympanum and is inserted along the inner 
border of the shaft of the malleus just below the neck, some 
of the fibers pass down for some distance along the handle 
and extend somewhat upon the anterior surface. 

The Stapedius. — The origin of this muscle is from the 
interior of the pyramid upon the postero-internal wall in 
front of and below the aqueductus Fallopii. The fibers con- 
verge to form a tenden which passes through the pyramidal 
apex and is inserted into the neck of the stapes at its junc- 
tion with the posterior crus. 

The muscles of the Eustachian tube are two, the tensor 
palati and levator palati. 

The tensor palati controls in a measure the lumen of 
the Eustachian tube. Its origin is from the scaphoid fossa 
and spine of the sphenoid anteriorly to the membranous 
portion of the tube, some fibers coming from the inferior 
border of the cartilaginous hook. The muscle passes down- 
ward in front of the membranous portion and converges 
into a tendon which encircles the hamular process of the 
sphenoid, then expands into a broad aponeurosis to be in- 
serted into the anterior surface of the soft palate and the 
posterior bony edge of the hard palate. The union of the 
fibers of the two muscles form the median raphe. 

The levator palati has its origin from the under surface 
and near the apex of the petrous portion of the temporal 
bone, and passes downward, forward, and inward to be in- 
serted in the posterior and superior surface of the soft 
palate. The body of the muscle is situated along and 
loosely attached to the inferior edge of the cartilaginous 
piate which constitutes the posterior tubal wall. It also is 
in contact with the fibrous inferior wall. 

The Arteries. — The arterial supply is principally from 
the branches of the external carotid, as well as a few 
branches from the internal carotid. The external carotid 



62 Nose, Throat and Ear. 

blanches supplying the auricle, canal, and tympanum, are 
the posterior auricular, superficial, temporal, occipital, in- 
ternal maxillary and ascending pharyngeal. 

The posterior auricular supplies the posterior portion of 
the auricle and canal. The stylomastoid branch passes 
through the stylomastoid foramen, supplying the mastoid 
cells and a special branch passes to the stapedius muscle 
and stapes. 

The superficial temporal supplies the anterior portion of 
the auricle and canal by means of the superior and inferior 
anterior auricular branches. Anastomoses of these 
branches with those of the posterior auricular practically 
complete the arterial supply of the auricle and canal. A 
small branch from the superficial temporal passes through 
the Glaserian fissure to the tympanum. 

The Occipital Artery. — Branches from this artery pass 
to the concha, entering from the cranial surface. 

The Internal Maxillary. — The most important blood sup- 
ply, especially in early life, is through the middle meningeal 
and tympanic branches. A few twigs are distributed to the 
Eustachian tube before entering the cranium. Inside the 
skull is the superficial, petrosal branch, which passes 
through the petro-squamous suture to the tympanum, to be 
distributed to the tympanic roof, malleus, incus, and part 
cf the internal tympanic wall, anastomosing with the laby- 
rinthine vessels. (Politzer.) Within the Fallopian canal it 
connects with the stylomastoid. 

The Tympanic Branch of the Internal Maxillary. — This 
branch passes through the Glaserian fissure and is distrib- 
uted to the anterior portion of the tympanum, anastomosing 
with the stylomastoid upon the periphery of the mcmbrana 
tympani. 

The internal tympanic wall is supplied by anastomoses 
of the tympanic artery with the tympanic branches of the 
internal carotid and the Vidian branch of the internal maxil- 



Ear. 63 

lary. Additional branches are from the internal maxillary, 
the Vidian, descending palatine, and pterygopalatine, which 
send small branches to the Eustachian tube and its muscles. 

Veins. — As a rule they accompany the arteries. The 
majority of the veins of the deeper structures form a plexus 
upon the superior and upper portion of the posterior wall 
of the external auditory canal. Those of the posterior wall 
and auricle empty into the external jugular and mastoid 
veins, the anterior branches joining the temporal and facial 
veins. A few of the deeper veins enter the pterygoid plexus. 
The veins of the Eustachian tube accompany the arteries 
and empty directly into the internal jugular vein, or some- 
times join the facial, lingual, or superior thyroid veins. 
There is a comparatively large venous trunk between the 
internal pterygoid muscle and adjacent wall of the tube, 
which passes to the cavernous sinus. 

Lymphatics. — The lymphatic canals are plentifully distrib- 
uted and anastomose with the superficial lymphatic glands 
and also those of the submucous system of the pharynx. 
The lymphatic channels of the canal and tympanum are in- 
timately associated with the superficial lymphatics over the 
mastoid, the lymph nodules in front of the auricle and those 
in the cervical region between the platysma and sterno-mas- 
toid muscles. There is also free lymphatic anastomoses 
through the glands of the lateral pharyngeal walls. The 
membrana tympani possesses three systems, one for each 
layer, which connect with each other and with the lymphatic 
system of the external canal. 

Nerves. — The nerve supply to the muscles of the con- 
ducting portion of the ear are from branches of the trigem- 
inus, facial, and cervical plexus. The attollens aurem is 
supplied through the occipitalis minor branch of the cervi- 
cal plexus. The tensor tympani and tensor palati muscles 
are supplied by the trigeminus through the otic ganglion, 



64 Nosk, Throat and Ear. 

and the rest of the muscles are supplied directly by the 
facial or through its ganglionic communications. 

The sensory nerves are from the cervical plexus, trigem- 
inus, pneumo-gastric, and glossopharyngeal. The auricle, 
superior portion of the meatus and tympanic membrane 
are supplied by the ariculo-temporal, a branch of the trigem- 
inus. The posterior portion of the auricle and meatus are 
supplied principally by the auricularis magnus derived from 
the cervical plexus, this branch anastomosing with the 
auricular branch of the pneumogastric upon the posterior 
wall of the canal. 

The auricular branch of the vagus supplies both the car- 
tilaginous portion of the canal and part of the posterior sur- 
face of the auricle. 

The tympanic branch of the glosso-pharyngeal reaches 
the tympanum through a foramen in the tympanic floor, and 
supplies the mucous membrane and Eustachian tube. It 
divides upon the internal wall, one branch anastomosing 
with the twigs of the carotid plexus from the sympathetic 
system, and forming the tympanic plexus. The second 
branch, the small, deep petrosal, passes through a foramen 
in the tegmen tympani to the small superficial petrosal 
nerve, which is the facial branch to the otic ganglion. The 
third branch passes from the tympanum and unites with 
the great superficial petrosal, the facial root of the Vidian 
nerve, the posterior branch of Meckel's ganglion. This 
branch is the great deep petrosal. 

The chorda tympani passes from the aqueductus Fallopii 
above the pyramid, crosses the tympanum from behind for- 
ward, and passes between the long process of the incus and 
the handle of the malleus. It passes from the tympanum 
through a separate canal close to the Glaserian fissure, and 
joins the lingual branch of the trigeminus. 

Histology. — The structures giving form to the external 
ear consist of bony and cartilaginous tissue, excepting the 



Ear. 65 

lobule, which is composed of dense fibrous tissue and fat. 
Subcutaneous tissue covers these structures and the whole 
i* covered by integument. The cartilage is the yellow 
elastic variety, forming a thin, tough plate, the irregulari- 
ties of which give the characteristic form to the ear. 

The skin covering the auricle is similar to the contigu- 
ous integument, but within the auditory canal some changes 
occur. The skin over the cartilaginous portion and part of 
the roof of the bony portion is quite thick as is the subcu- 
taneous tissue. Fine hairs, sebaceous and ceruminous glands 
are distributed in this portion pf the canal. The skin cov- 
ering the most of the bony portion of the canal, however, is 
thin and closely connected with the periosteum. Glands 
and hairs are absent in this portion, as well as in the integu- 
ment reflected over the external surface of the membrana 
tympani. 

The membrana tympani consists of three layers; (1) 
outer or reflected cutaneous layer, (2) middle or lamina 
propria, consisting of fibrous connective tissue; (3) inner 
or mucous layer, consisting of a portion of the lining of the 
tympanic cavity. The outer layer is composed of the epi- 
dermis and connective tissue corium, the latter being about 
one-half as thick at the epithelial layer. The lamina propria 
composes the fibrous structure of the membrane and rep- 
resents its mesodermic portion. It consists of two strata 
of finely felted fibrous tissue bundles. In the radial or outer, 
the tendency is for the bundles to radiate from the. tip of 
the malleus toward the periphery, while the circular, or 
inner, are concentrically arranged bundles, the greatest de- 
velopment being at the periphery near the annular attach- 
ment of the membrana tympani. The mucous layer, a con- 
tinuation of the tympanic mucous membrane, comprises a 
thin connective tissue ground work of delicate fibro-elastic 
tissue bundles, covered by a single layer of low cuboidal 
polyhedral celled epithelium destitute of cilia. 
5 



66 Nose, Throat and Bar. 

The blood supply is from two sources ; the external from 
the branches supplying the external auditory canal, the 
capillaries being distributed within the cutaneous layer, 
while the internal is derived from the vessels of the tympanic 
cavity, which are distributed to the mucous layer. 

The lymphatic system corresponds to the principal strata. 

The nerve supply is similar to that of the blood, being 
external and internal; the external, or cutaneous, being 
more or less from the tympanic branch of the auriculotem- 
poral, which passes beneath the manubrium and divides at 
the lower third of the process into two terminal twigs. Be- 
sides these central nerves, filaments enter the periphery of 
the membrane at different points, and uniting with the 
others form a wide meshed plexus, which sends filaments 
to and surrounds the blood vessels. A sub-epithelial plexus 
is also formed from this net work. The tympanic plexus 
sends nerves to the mucous layer, being distributed to the 
lymphatic and blood systems, as well as a sub-epithelial 
plexus, and a few twigs into the lamina propria. 

The: MiddIvE Ear. — This constitutes the entodermic di- 
vision of the ear, and comprises the tympanic cavity with 
the communicating mastoid cells, the ossicles and Eusta- 
chian tube. The tympanic cavity is enclosed within bony 
structures covered with periosteum, over which is the mu- 
cous membrane which is indirectly continuous with the 
pharyngeal mucous membrane. The mucous membrane is 
closely adherent to the periosteum, but also covers the os- 
sicles and their ligaments, as well as the nerves and blood- 
vessels crossing the middle ear. The mucosa is composed 
of a thin fibrous tissue resembling in some places the re- 
ticulum of adenoid tissue ; the mucous layer is closely con- 
nected with the fibrous structure of the periosteum. 

The epithelial surface of the tympanic cavity varies in 
structure ; that covering the ossicles, membrana tympani, 
promontory and the mastoid cells, is a single layer of low 






Ear = 67 

cuboidal, polygonal non-ciliated cells, the rest of the sur- 
face consisting of the ciliated columnar type. Where nerve 
trunks or blood vessels are located, the mucosa is much 
thickened, forming ridges over them. Small tubular glands 
are sparsely located in the mucous membrane of the an- 
terior portion of the cavity. The mucous membrane cover- 
ing the antrum and mastoid cells is very thin and delicate. 

The structure of the secondary tympanic membrane 
which closes the fenestra rotunda is ; externally the tym- 
panic mucous membrane, composed of a layer of flattened 
non-ciliated polyhedral cells, and a thin fibrous tunica pro- 
pria ; the lamina propria consists of radially placed bundles 
of fibrous tissue passing from the indurated point of the 
base towards the periphery; the inner consists of a thin 
layer of sub-endothelial fibrous tissue covered by a layer of 
endothelial plates. 

The blood vessels of the tympanic mucous membrane 
are situated in the deeper periosteal layer of the mucosa, 
sending branches to the membrane. 

Lymphatics. — Within the deep periosteal layer are sit- 
uated the lymphatics. In the reticular connective tissue of 
the mucosa are found groups of lymphoid cells giving the 
appearance of lymphatic nodules. 

Nerves. — The principal nerves of this region are derived 
from the tympanic plexus, and consist almost entirely of 
medullated fibers lying within the periosteal layer of the 
mucosa. A sub-epithelial net work of pale non-medullated 
fibers is derived from a plexus formed by the deeper trunks. 
Ganglion cells are sometimes found along the course of the 
larger trunks and their branches. 

The ossicles are compact bone, the thicker parts con- 
taining Haversian canals and concentric lamellae. Hyaline 
cartilage invests all surfaces of contact. A minute intra- 
articular plate of fibrous cartilage is interposed in the cavity 
of the ambo-malleal articulation. The malleus throughout 



68 Nose, Throat and Ear. 

its entire attachment with the membrana tympani is cov- 
ered by an investment of cartilage, the perichondrium and 
fibrous tissue of the lamina propria becoming firmly united. 
A plate of cartilage also covers the base of the stapes which 
connects with the fenestra ovalis. The annular ligament, 
consisting of fibrous tissue, occupies the remainder of the 
fenestra ovalis. 

The: Eustachian Tube:. — This consists of two parts, 
bone and cartilage composing the frame work, and the 
mucous membrane. Complete walls are not formed, the 
completion of the tube being by means of fibrous and other 
tissues. Mucous membrane lines the entire tube, the por- 
tion below the firm structure having a layer of sub-mucous 
tissue, but in the upper part it is intimately united with the 
periosteum of the bony walls. The epithelium of the tube 
is of the ciliated stratified columnar type, that of the 
pharyngeal portion being of the tall columnar, and that 
of the tympanic portion the low cuboidal type. The tunica 
propria is composed of loose connective tissue. 

Lymphoid cells in many places are distributed in the 
reticular connective tissue constituting an adenoid structure. 
This distribution varies with age, being most generally dis- 
tributed in childhood, but in adolesence being confined al- 
most entirely to the lower third. At the pharyngeal end 
small mucous glands are constant, but they may occur 
throughout the entire tube. 

Sub-mucous Layer. — In the cartilaginous portion of the 
tube the sub-mucous layer is well developed and is com- 
posed of fibro-elastic tissue. 

Blood Vessels. — The blood supply to the mucous mem- 
brane is from the tympanic and pharyngeal vessels. 

Nerves. — These are derived from the tympanic and 
pharyngeal plexuses, and are situated in the deeper mucosa 
layers, filaments reaching the epithelial surface. 



tun Inner Ear. 



6 9 



The Inner Ear, or Receptive Portion. 

Under this heading the inner ear, auditory nerve and 
its origin ai e necessarily included. 

The internal ear proper consists of the bony and mem- 
branous labyrinth. The bony portion consists of a series of 
communicating cavities in the petrous portion of the tem- 
poral bone, filled with fluid, the perilymph, in which the 
membranous labyrinth is suspended. This latter portion is 
composed of a series of membranous tubes which corre- 



jerri^g- 




Hamulus 



cochUat 



The bony Labyrinth. 

Fig. 23. 



spond in general contour to the bony portion, and these tubes 
are also filled with fluid, the endolymph. 

The Bony Labyrinth. — This may be Considered as a cen- 
tral cavity, the vestibule, from which tortuous canals di- 
verge. This central cavity is ovoid in shape, the vertical 
diameter being the longest, measuring about a quarter of an 
inch. The short diameter is about one-fifth of an inch. The 
outer wall presents the foramen ovale, which normally is 
closed by the foot-plate of the stapes. 

The inner wall contains two fossae, separated by a bony 
spine, the crista vestibuli. The anterior fossa, the recessus 



7o 



Nose, Throat and Ear. 



sphericus, lodges the saccule. The posterior fossa, the re- 
cessus ellipticus, lodges the utricle. 

The posterior wall contains the openings of the three 
semi-circular canals. There are five openings, as the supe- 
rior and posterior canals enter the vestibule by one opening. 
The cochlear canal entrance occupies the place of the an- 
terior wall of the vestibule. Near the border of the re- 
Cessus ellipticus is a small opening, the orifice of the aque- 
ductus vestibuli, through which the cavities of the mem- 
branous labyrinth communicate with the subdural space. 



x SupF semicircular Canal. 

rsermctrcu-lcvr Canal 



J?jc£± ' semi<<nrcuS*vrGcinfil 




<4qu£Bduc£tls Fallopii 
CbcfU&v 

Cctrotut Canal 



vramcn ovale 
JFbrcurven, roturutum. 



FiG; 24. Bony labyrinth as seen from behind. 



The Semi-Circular Canals. — These are so placed that 
the plane of each is perpendicular to that of the other two. 
These canals are the superior, posterior, and external. The 
posterior lies in the vertical plane of the long axis of the 
petrous portion of the temporal bone. The superior is at 
right angles to the posterior, and is also vertical. The ex- 
ternal is in the horizontal plane. The point of origin and 
termination of each is the vestibule. The extremities of the 
canals, with the exception of the common opening, are di- 
lated, forming an ampulla for each. 



The Inner Ear. 



7* 



The Cochlea. — The opening- of this is at the anterior 
and inferior surface of the vestibule. It is a bony tube coiled 
two and one-half times about a bony axis, the modiolus. 
Extending from this axis into the cavity of the tube, and 
partially dividing it, is a thin septum of bone, the lamina 
spiralis, composed of two thin plates. This bony lamina 

A 



slqutapducLics FallopLZs 
Hiatus TailopM. 



Or % oo vcfor Grea/erPetrot 

Cochlea, 
In f ( . Auxiliary Mealu, 

Sup r sem i circular Ciifixi^ 
Post r semvCt rcuJ-tU 



Jlxt l ' sesn-WircuUtr CctruzL 




FiG. 25. Bony labyrinth as seen from above. 

does not extend quite to the outer wall, a membranous sep- 
tum completing the division' of the cochlear tube. This 
portion is called the lamina spiralis membranacea. The 
bony lamina commences at the fenestra rotunda and extends 
to the cupola, where it ends in a somewhat hook-shaped 
process, the hamular process. The superior division of the 
canal is called the scala vestibuli, and the inferior the scala 



72 Nose, Throa? and Ear. 

tympani. A second membrane divides a portion of the 
scala vestibuli, forming the scala media or ductus cochleae, 
this really belongs to the membranous labyrinth. 

The terminal half turn of the cochlea forms the cupola. 
At the apex of the cochlea there is a foramen between the 
soalse tympani and vestibuli, the helicotrema. 

There are numerous canals traversing the modiolus, the 
largest passing through the center from the base to the 
cupola is the canalis centralis modioli, and contains a small 
nerve and artery. A small opening, the aqueductus cochleae, 
leads to a canal inclosing a small vein, and opens on the 
basilar surface of the temporal bone. A swelling of the 
cochlear nerve, the ganglion spirale, is contained in a small 
canal, the canalis spiralis modioli, which twists around the 
modiolus and lies at the point where the bony lamina is at- 
tached to the modiolus. Ganglion cells are found in the 
g'anglion spirale, which give off branches that pass through 
the bony lamina to the organ of Corti. 

The termination of the lamina spiralis is curved, and is 
called the sulcus spiralis internus, the upper lip the labium 
vestibulare, the lower lip the labium tympanicum. The 
crista spiralis is between the labium vestibulare and the 
origin of Reissner's membrane. 

The scala tympani is completed by the membrana basi- 
jlaris, a delicate membrane which extends from the labium 
tympanicum to the ligamentum spirale, which appears as 
an expansion of the basilar membrane attached to the outer 
bony wall of the cochlea. 

The stria vascularis is a thin layer of cells resting on 
that portion of the ligamentum spirale between the attach- 
ment of Reissner's membrane and the prominentia spiralis. 
The sulcus spiralis externus is between the prominentia 
spiralis and the attachment of the membrana basilaris, the 
point of attachment of the membrane being the crista basi- 
laris. The membrane of Reissner reaches from the vestibular 



The Inner Bar. 73 

surface of the periosteum of the bony lamina to the ligamen- 
tum spirale, forming the upper limit of the scala media, the 
lower limit being the membrana basilaris. The membrane 
of Corti, or membrana tectoria, is a delicate structure ex- 
tending from the attachment of Reissner's membrane and 
the labium vestibulare to the outer row of hair cells. 

The Organ of Corti. — This consists of numerous rods or 
cells resting on the basilar membrane and covered by the 
membrana tectoria. The two central rows of cells are rod- 
like and are the inner and outer rods of Corti, which rest 
upon the basilar membrane. They are separated at 'the base, 
but lean towards each other, forming a small canal, the zona 
arcuata, which extends throughout the cochlea in a spiral 
direction. Within the zona arcuata are two rows of cells, 
one in each angle formed by the rods of Corti with the 
basilar membrane, and called the floor cells. Nerve fibers 
cross the zona arcuata to the outer hair cells. 

The outer hair cells are usually described as consisting 
of three to five rows. They are situated externally to the 
cuter rods of Corti, their broad ends directed upwards. 
The cells of Deiter are between these rows, the broad ends 
of which are directed downwards. A single row of inner 
hair cells, smaller than the outer, are situated to the inner 
side of the inner rods of Corti. A layer of supporting cells 
continuous with the epithelial lining of the sulcus spiralis 
interims, is on the inner side of these hair cells. A thin 
reticulated membrane, membrana reticulata, or Kolliker's 
membrane, covers and is in contact with the upper ends of 
the rods of Corti and outer hair cells. Openings through 
this membrane allow the passage of the cilia of the outer 
cells. This membrane appears to bind the cells together. 

On the outer side of the organ of Corti, probably for 
its support, is a cell structure, the cells of the upper portion 
being the supporting cells of Hensen, while those of the 
lower outer portion, resting on the basilar membrane to the 



74 Nose, Throat and Ear. • 

crista basilaris, are the cells of Claudius, these have a large 
number of small nuclei. 

The membranous labyrinth comprises the membranous 
semicircular canals, the utricle, and the saccule. 

The membranous canals correspond in number, arrange- 
ment, and general form to the bony canals, but are about 
One-third the size of the bony canals. They have five open- 
ings into the utricle corresponding to the bony orifices. The 
ampullae are the thickest portions of the canals. Three 
layers compose the membranous canals, the inner being of 
polygonal nucleated epithelial cells which secrete the fluid 
'endolymph contained within the membranous canals. The 
middle layer is a compact, nearly homogeneous layer, cor- 
responding to a highly developed basement membrane. The 
cuter layer is of felted connective tissue bundles containing 
many cells. Inclosed within the bony canals, and surround- 
ing the membranous canals is a fluid perilymph quite similar 
to the endolymph. The vestibular nerve sends filaments to 
the ampullae. 

The Utricle. — This is oblong and is in contact with the 
recessus ellipticus. On the anterior and lateral walls of 
the utricle, corresponding to their attachment to the bony 
wall, there is a thickening, caused by a grouping of the 
lining cells, which projects somewhat into the cavity of the 
utricle. This ridge is the macula acustica, and is covered 
by specialized epithelium, consisting of ciliated, or hair 
cells, between which are situated supporting cells. A clear, 
transparent semifluid material covers the specialized epithe- 
lium of the macula acustica, which contains crystals of car- 
bonate of lime, the otoliths. 

The Saccule. — This is spherical and located in the re- 
cessus sphericus. There is no apparent communication be- 
tween the cavities of the saccule and utricle. There is a 
macula acustica, and also otoliths as in the utricle. A small 
canal, canalis reuniens, connects the saccule with the ductus 



Thk Innkr Kar. 75 

cochlearis of the membranous labyrinth. Stiff cilia, audi- 
tory hairs, project from the macula in both the saccule and 
utricle, which are connected with nerve filaments from the 
auditory nerve. 

The Arteries. — The arterial supply of the labyrinth is 
from (i) the internal auditory, a branch of the basilar, 
and the principle source of supply; (2) branches from 
the occipital; (3) the stylomastoid, from the posterior au- 
ricular. 

The internal auditory divides at the bottom of the in- 
ternal auditory meatus into the cochlear and vestibular 
branches. By means of numerous small branches from the 
cochlear, which pass through the canals in the modiolus 
and enter the substance of the lamina spiralis, a capillary net- 
work is formed. The membranous labyrinth is supplied by 
a capillary network from the vestibular division. 

Veins. — The veins from the different divisions unite 
with the superior petrosal sinus. 

The; Auditory Nerve. — The auditory nerve, nerve of 
hearing (portio mollis), has its superficial origin at the 
lower border of the pons from a groove between the olivary 
and restiform bodies. Two deep origins are from the fourth 
ventricle. The nerve winds around the restiform body, and 
accompanies" the facial nerve across the posterior border of 
the middle peduncle of the cerebellum to enter the internal 
auditory meatus. At the bottom of the meatus the facial 
nerve enters the aqueductus Fallopii. 

The auditory nerve divides at the bottom of the meatus 
into the cochlear and vestibular branches. The vestibular 
subdivides into the superior, middle, and inferior portions, 
which are distributed to the cristse acusticae of the semi- 
circular canals, and the maculae acusticae of the utricle and 
saccule. The cochlear subdivides into numerous small 
branches, and entering the base of the modiolus, passes be- 
tween the plates of the bony lamina spiralis where a plexus 



76 Nose, TiIroat and Ear. 

is formed, the ganglion spirale. Nerve filaments are dis- 
tributed from this plexus to the sulcus spiralis and organ 
of Corti. 

The inner ear in its development represents ectodermic 
and mesodermic tissue, while the middle and external ear 
contain ectodermic, mesodermic, and entodermic la vers. 



CHAPTER III. 

EXAMINATION. 

Success in treating diseases of the ear, nose,* or throat 
does not depend alone upon a knowledge of the anatomy 
and physiology of these structures, but an inspection of 
the parts must be made ; this means, not only an anatomical 
but also a positive knowledge of the structures examined. 
Variations in individual cases must also be taken into con- 
sideration, as otherwise a normal might be mistaken for a 
morbid condition. 




Fig. 26. Adjustable swingin 



The character of the light used will also make a differ- 
ence. A light with a yellowish tinge intensifies the color 
of tissue. The ideal light is a diffuse, clear day light, but 
unfortunately this is seldom obtainable, artificial illumination 
having to be resorted to in the majority of instances. My 
preference is the argand gas burner for office work, as being 
most easily controlled, and giving less variation in the ap- 
pearance of tissues than when other means of illumination 
are employed. If a diffuse electric light were obtainable, it 
would prove still better, and would compare favorably with 

77 



7 8 



Nose, Throat and Ear. 



daylight. A portable battery with diagnostic lamps, may in 
many instances be employed. 

Head Mirror. — The head mirror is almost an indispen- 
sable article, and as it can be used under any and all con- 
ditions, is especially important. The size varies from three 
inches to four and one-half inches, but the most comfortable 
to wear, and one also which gives a good illumination, is 
the three and one-half inch. Larger than this they are cum- 
bersome. • These mirrors are concave, with an aperture in 
the center. The focal distance varies from eight inches to 
fifteen inches, but a choice of focal distance should be such 




Fig. 27. Head mirror. 



Fig. 28. Scliroetter head band. 



as will allow the wearer the best illumination and use of 
jthe eyes with comfort. The mirror should be attached by a 
ball and socket joint to some form of head band, and the 
Schroetter band with nose rest is the most comfortable, al- 
though some prefer the metal band with an occipital pad. 
This is simply a matter of individual preference.- 

The method of wearing the mirror may be either by 
bringing the central opening opposite one eye, or with the 
mirror over the forehead. Both methods should be prac- 
ticed, as each possesses advantages, but for general pur- 
poses, better results are obtained by the forehead position, 
as this allows binocular single vision. 



Examination. 



79 



An electric head lamp may be used instead of a mirror, 
and in some operative measures is best. 

Rhinoscopic and laryngoscopic mirrors with an universal 
handle are necessary. Different sizes of these should be 
obtained, and the rod on which the mirror is fastened should 
be flexible, as often it is necessary to change the angle in 
order to obtain a good view of the parts. The sizes are o 
to 5, Xo. 4 laryngoscopic being the most generally useful 
for laryngoscopic, and Xo. I rhinoscopic for nasal work, 
but as the size used will depend upon the case, an assort- 




FiG. 29. WorraU's folding spring head band. 

ment is preferable. A tongue depressor, the style of which 
will depend upon individual preference. A nasal speculum, 
the wire speculum being in most respects desirable, as if 
properly made it will in the majority of cases be practically 
self-retaining. A probe is also necessary. Ear speculums, 
either of hard rubber or metal, of the Gruber pattern. For 
general work the hard rubber are best. This list comprises 
the essential instruments for general use. 



Examination of the Nose and Throat. 
Revolving chairs or stools which can be raised or low- 
ered, are the most useful, as in this way the position of 



80 Nose, Throat and Bar. 

examiner and patient can be regulated. The light, when it 
can be arranged, should be on a swinging bracket which 
can also be raised or lowered, or a floor stand. The light 
should be to the right of the patient, a little above Jhe ear, 
and not so close as to inconvenience the patient by the heat. 
Practice in the use of the head mirror will enable the ex- 
aminer to keep the parts illuminated. It is better to adopt 
a routine method of examination, as in this way one is 
less liable to overlook some of the structures. Except- 
ing in rare instances, it is better to commence with the nose. 
Anterior rhinoscopy is the term employed for examin- 
ing the nasal fossae through the nostrils. The nostril may 
be dilated with a speculum, or by pressing the tip of the 




Fig. 30. Author's wire speculum. 

nose upwards and backwards with the thumb. The latter 
method is not satisfactory in many cases, and recourse to the 
speculum is necessary. The usual method of using the 
speculum is to place the blades against the outer and inner 
walls of the nostril, but as a rule this is painful, and for an 
examination the blades resting against the anterior and 
posterior surfaces of the nostril will be sufficient to give a 
good view of the nasal cavity, and the patient will seldom 
complain of any discomfort. Before introducing the specu- 
lum, the tip of the nose should be raised to obtain a view of 
the fossae, as at times there may be so much deflection of 
the septum that it will be impossible to introduce a speculum, 
and at times small pustules are located just within the nos- 
tril, and the pressure of the speculum will cause an un- 
necessary amount of pain. 



Examination. 8i 

The position of the head is important. For examining 
the floor of the nose, the head should be held forward and 
slightly downward, on account of the anatomical forma- 
tion. For the middle- turbinate the head should be in the 
natural position, and for the superior portion of the nasal 
cavity the head should be tipped backward. In this way 
the anterior portion of the nasal cavities can be examined. 

Posterior Rhinoscopy. — Excepting in young children 
this can usually be accomplished without much difficulty, 
provided attention is given to a few rules. The rhinoscopic 
mirror should be slightly warmed, which is readily accom- 
plished by passing it over the top of the gas or lamp chim- 
ney. The degree of heat can be determined by pressing the 
back of the mirror, preferably, on the back of the hand. It 
should not be too warm, neither so cool that the moisture 
from the breath condenses on the surface of the mirror, as 
then a clear image will not be obtained. The patient should 
be instructed to breathe naturally and through the nose. 
Then have the patient open the mouth gradually, still 
breathing through the nose, as in this way the soft palate 
remains relaxed. The mirror is held loosely in the same 
position as a pen, the shank resting upon the tip of the mid- 
dle finger and steadied by the thumb and tip of the index 
finger, the thumb also serving to rotate the mirror. The 
arm and forearm should be held in an easy position, other- 
wise it will be difficult to manipulate the mirror. It is al- 
ways better for the operator to be ambidextrous in handling 
instruments, as thus operative procedures can be better per- 
formed. The mirror should be introduced into the mouth, 
keeping to the side corresponding to the hand the mirror is 
held in, passing diagonally backward, through the faucial 
space and back of the uvula, care being taken not to touch 
the surrounding structures. When free in the pharyngeal 
space, the handle of the mirror is rotated to bring the re- 
flecting surface upward and forward. The position of the 
6 



82 Nosk, Throat and Ear. 

mirror is easily changed, either as regards the angle of the 
reflecting surface or rotated as required without wrist mo- 
tion, which would in all probability cause the tissues to be 
touched, causing the patient to gag. 

In examinations of the nose and throat, the best results 
are obtained when the period of examination is limited to a 
few seconds, if patients are sensitive, as the dread of an ex- 
amination with the majority amounts to positive dread, and 
only as confidence is established, will a prolonged examina- 
tion be tolerated. It is advisable to make several attempts 



Fig. 31. Kyle's tongue controller. 

the first or second sitting, rather than weary the patient. In 
many cases, unless they have taken vocal lessons, it is 
necessary to use a tongue depressor for posterior rhinoscopic 
examinations. 

Hinged depressors should be avoided, as it is almost im- 
possible to keep them clean. In using the depressor, the 
patient should be instructed to open the mouth, allowing 
the tongue to assume a position with the tip against the 
lower teeth. The depressor being slightly warmed should 
be introduced, not too far back, as the base of the tongue is 
extremely sensitive, and considerable resistance will be made, 
interfering with the use of the mirror. The pressure 



Examination. 83 

should be steady, and directed downward and forward, 
when the most space will usually be obtained. The largest 
mirror that the space will allow should be used, as the il- 
lumination and size of the image will both be increased. In 
some cases it is impossible to obtain a view on ac- 
count of the patient's inability to control the muscles of 
the pharynx and soft palate. In such cases, a solution of 
cocaine may be used to allay sensitiveness, or better the 
auto-spray of 2 per cent cocaine in Kelene. This should be 
a last resort. 

The various instruments devised for retracting the soft 
palate are of little use. 

In some cases a small incandescent electric light in the 
post nasal Space may be advantageously employed. The 
introduction of the lamp is readily made by following the 
rules for the rhinoscopic mirror. When the lamp is in posi- 
tion, the patient closes the teeth upon the shank, which 
holds the lamp in position. The lamp is protected by a per- 
forated cap which allows transmission of the light and also 
protects the- tissues from the heat naturally generated. The 
cap is movable, so the direction of the rays of light can be 
controlled. A good view of the anterior nares can be had 
in this way, and also- considerable of the posterior portion. 
The condition of the accessory cavities can also be fairly 
well determined, but an anomalous condition must be con- 
sidered, as otherwise the interrupted transmission of light 
might lead to a diagnosis of fluids or tumors when they 
are absent. 

In order to determine whether a normal or abnormal 
condition is present, it is necessary to keep a mental picture 
of normal structures well in mind. 

In the anterior examination, the head positions already 
described will allow inspection of the various structures, 
the turbinates on the outer portion of each nasal cavity, 
and the septum in the median line. By having the patient 



84 Nose, Throat and Bar. 

incline the head to the right or left, a more extensive view 
will be obtained, and as the head is thrown backward, the 
structures, and in some cases, even the superior turbinates 
and roof of the nasal cavity can be inspected. 

The color of the normal mucous membrane is, on the 
septum a bright pink, a little darker at the junction with 
the floor of the nose. The anterior portion of the middle 
turbinate is dark pink, the superior turbinate pink with a 
yellowish tinge, the roof a more marked yellowish pink, 
but of lighter shade, and the balance of the structures show 
a grayish pink color. 

The rhinoscopic mirror will show, as the mirror is manip- 
ulated to bring the different portions into view, the oval- 
shaped openings of the choanse or posterior nares. It must 
always be remembered that in these views the position of 
the parts as seen in the mirror are reversed. Usually the 
septum will be first distinguished broader above and taper- 
ing as it approaches the floor of the nose. On each side 
may be seen, as in a slight shadow, the openings of the 
nasal passages. By slightly turning the mirror, the in- 
ferior turbinate may be seen, resembling a pinkish gray, 
elongated mass, and apparently resting upon the floor of 
the nose. Above this the middle meatus will be seen. 
Above the middle meatus the middle turbinate appears, as 
a somewhat elongated and slightly fusiform projection, the 
edges yellowish red, the color becoming deeper towards 
the base. 

The superior meatus appears as a dark line above the 
posterior portion of the middle turbinate, separating the 
middle and superior turbinates. The superior turbinate is 
indistinctly seen as a light reddish band and can not be 
clearly defined excepting by the post nasal lamp. The color 
is the same as the middle turbinate and the edge slants up- 
ward and forward, appearing as though suspended from 
the roof. 



Examination. 



85 



It is seldom that a satisfactory view of the inferior 
meatus and floor of the nose can be obtained by the use of 
the mirror, but a very fair idea of the parts can often be ob- 
tained by an anterior examination. 

The opening of the Eustachian tube generally appears 
as a grayish; funnel-shaped depression, the eminence sur- 
rounding it and Rosenmuller's fossa separating the Eu- 
stachian eminence from the posterior pharyngeal wall, may 
be inspected by turning the face of the mirror to one side. 

To inspect the vault of the pharynx, the handle of the 




Fig. 32. Posterior view of the nose, showing adenoids in the 
vault of the pharynx, and hypertrophies of the inferior turbinates. 

mirror should be elevated, thus bringing the mirror nearer 
the horizontal, which will bring the half dome-shaped vault 
of the pharynx into the field. 

The outline is somewhat irregular owing to the glandu- 
lar tissue present. The age of the patient usually deter- 
mines the amount of this tissue, in the adult it generally has 
atrophied more or less. This tissue, the pharyngeal or 
Luschka's tonsil is always present in children, and may be 
normal or very much enlarged. The enlargement may be a 
swelling or an actual proliferation of tissue. The color of 



86 Nose, Throat and Ear. 

the pharyngeal tonsil varies, in the young often being a 
deep red color, and in the adult a pinkish gray. The sur- 
face becomes smoother toward the pharynx, where a smooth 
dark red color is present. A view of the pharyngeal vault 
is not only usually difficult to obtain in children, but often 
impossible, but a fair idea of the condition may be obtained 
by introducing the index finger back of the soft palate, and 
pressing it over the tissues. This procedure, however, is 
not advisable, as a rule, unless the child has been given an 
anesthetic sufficient to prevent struggling, as the fright pro- 
duced will make it very difficult afterwards to do anything 
with the child. 

In prolonged examinations the color of the tissues 




Fi. 33G. DeVilbiss Atomizer. 

changes, probably through both the influence of the re- 
flected light as well as the action of the muscles. 

Office Requisites. — Some instruments are required for 
office treatment. For cleansing the mucous membranes, 
numerous appliances have been devised. Cotton applicators, 
atomizers, douches, and syringes, all have their advantages 
and disadvantages. Atomizers of numerous kinds are to be 
obtained, but the simplest in construction is most desirable, 
and the hand atomizer will prove as satisfactory, in fact, 
more so usually than the complicated and cumbersome com- 
pressed air apparatus, as the force often employed in the 
latter will aggravate many conditions. With a straight tube 
atomizer, not only the nasal passages, but also the naso- 



Examination. 87 

pharynx can usually be thoroughly cleansed, but the tube 
should be of metal and not exceed one-eighth inch in diame- 
ter. In nearly all cases the spray can be directed so the en- 
tire anterior portion can be reached, and with but few ex- 
ceptions the tube can be passed through the nasal cavity far 
enough to reach the post nasal space. The curved tips 
often furnish with atomizers for spraying the pharyngeal 
vault are practically worthless as a rule, for few persons 
can use them, and at times spasmodic contraction of the 
velum on the tip holds it so firmly that it is difficult to 
remove without lacerating the tissues. 

An objection to atomizers is that when the secretion is 
very tenacious, it is almost impossible to cleanse the tissues 
thoroughly. 

Douches of various kinds are used, but the objection to 
them is, that if the fluid enters the nasal cavities with much 
force, it will produce congestion of the tissues, often in- 
creasing a rhinitis. Besides, unless carefully used, there is 
danger of forcing some of the secretion or fluid into the 
Eustachian tubes, or possibly into the maxillary sinus. The 
fluid also seldom reaches any portion but the respiratory 
tract, and if there is an abundant secretion, it will only par- 
tially do the work. 

Syringes have also been employed, the post nasal 
syringe especially. In this method the secretions are swept 
forward through the nasal cavities and theoretically it is the 
proper method, but it is not easily used, especially in 
children, and there is danger of forcing fluid into the 
Eustachian tube. The instrument I have found most useful 
and with the fewest objections, is the "Success Nasal 
Syringe." Much or little force can be employed in empty- 
ing the bulb, and the danger of forcing fluids into either 
the accessory cavities or Eustachion tubes is reduced to a 
minimum. The parts can be cleansed more thoroughly 
than by an atomizer, and there is less liability of producing 



8$ 



Nose, Throat and Ear. 



congestion than with the douche. The tubing being soft 
rubber, there is little danger of injuring the tissues. What- 
ever form of cleansing apparatus is used, the fluid employed 
should be practically at blood heat, and what is also im- 
portant, is that the specific gravity of the fluid should ap- 
proximate that of the blood, otherwise the osmosis produced 
renders the patient uncomfortable. 

In the use of any fluid, it must be remembered that an 




Fig. 34. Cotton holder. 



arbitrary rule can not be followed, but that each individual 
case must be studied, and the preparation modified to suit 
the condition present, also that as improvement takes place, 
changes must be made. 

The use of cotton applicators is frequently necessary, 
as by no other method can the surfaces be perfectly cleansed, 
but care in their use is imperative, as otherwise injury of the 
tissues results. All manipulations should be carefully per- 
formed. 



Examination. 89 

After the structures are thoroughly cleansed, a more ac- 
curate idea of the condition of the tissues can be obtained 
than is otherwise possible. 

In some few cases it is necessary to use powders in the 
nose, and of the various instruments those which will dis- 
tribute the powder in a fine cloud, are to be preferred to 
those which throw them in a mass. The DeVilbiss is a 
favorite, although there are several other good instruments 
in the market. 

Nebulizers and inhalers are of value in some cases, al- 
though too much reliance must not be placed upon local 
measures, as constitutional treatment is of the utmost im- 
portance if satisfactory results are to be -obtained. As re- 




ik MAX WOCHER &. SON, OIN., O. 




FiG. 35. DeVilbiss powder blower. 

gards nebulizers, their long continued use will cause ab- 
sorption. of the oily base, and produce a chronic thickening 
which is very annoying. It is true that after the use of 
aqueous solutions, especially in cold weather, the oily prepa- 
ration afterward is a protection to the mucous membranes, 
but patients are prone to abuse their use, and will provide 
themsefyes with a small oil atomizer, and use it too fre- 
quently. 

The use of a hot air, or vapor, apparatus is often bene- 
ficial, more especially in middle ear affections, but in the ac- 
cessory sinuses the relief is only temporary, as a rule, still 
this is often of considerable importance. Inhalers for using 
steam or medicated vapors may be extemporized by using a 



90 Nose, Throat and Bar. 

pitcher or small double boiler, such as is used for cooking, 
rilling the outer boiler with hot water, and placing the medi- 
cine needed in the inner vessel over which a cone, made by 
folding a towel or paper, may be used to inhale the vapor. 




Fig. 36. Office cabinet with atomizers and nebulizers. 

Pharyngeal Examination. — Inspect the condition of 
the teeth, whether carious or not, the shape of the hard palate, 
whether symmetrical or not, also as to the palatal arch, 
which if very high may cause stenosis of the nasal cavities. 



Examination. 



9i 



-The appearance of the velum, whether thickened, thinned, 
or relaxed, also its color and symmetry, a slight asymmetry 
may be normal. The uvula should also be inspected, as to 
size and length. If long enough to rest upon the base of the 
tongue, it will probably cause a constant irritation, produc- 
ing an irritative characteristic cough. The shape and size 
of the tongue should be noted, as this often eliminates 
systemic conditions. A coated tongue, when not dependent 
upon an acute disease or alimentary disturbance, may 
usually be referred to mouth breathing. 

The tonsils are normally nearly hidden by the faucial 




Fig. 37. Spray bottle holder for warming solutions. 

pillars, but may be exposed to view by "gagging" the pa- 
tient, or drawing the anterior pillar to one side by some in- 
strument. If the tonsil presents a roughened surface, or 
prominent points, there is an abnormal condition. The 
color of the normal tonsil is the same as of the surrounding 
tissues, and any departure from this indicates disease. Ad- 
hesion of the tonsil to the faucial pillars is usually the re- 
sult of ulceration. The tonsils are connected by an adenoid 
tissue formation extending along the base or root of the 
tongue and in front of the epiglottis. This is termed the 
lingual, or fourth tonsil, and consists of a row of small 



92 Nose, Throat and Ear. 

papules. Normally this structure is not readily seen, ex- 
cepting by the use of the laryngoscopic mirror. This tis- 
sue is subject to the same changes through inflammatory 
action as the other pharyngeal tissues. The normal color 
of the pharyngeal surface is a pale pink, and there is the 
appearance of the mucous membrane resting on a resilient 
cushion. Changes in color, apparent thinning, thickening, 
or roughening of the surface indicates morbi'd changes 
which may be acute or chronic. While in a normal state 
the mucous membrane appears moist, there is no excess of 
secretion, but in morbid changes there is either an excess 




Fig. 38. Proper position of patient's head and 
the mirror to obtain the laryngeal image. 

or deficiency. By having the patient say ah! the velum 
will be retracted, not only showing whether symmetrical 
action of the muscles exists, but also exposing the posterior 
pharyngeal wall to about the level of the palatal arch. By 
causing the patient to gag, the action of the pharyngeal 
muscles will expose the lateral walls which otherwise are 
hidden by the posterior faucial pillars, and the condition of 
the tissues in these regions can be determined. 

Laryngoscopy. — The mirror should be warmed as di- 
rected for the rhinoscopic mirror. The patient should sit 
erect or with the body slightly inclined forward. With 



Examination. 



93 



the mirror in readiness the patient should be instructed to 
breathe naturally, and while breathing in this manner, open 
the mouth and protrude the tongue. In the physician's 
left hand should be a small napkin, pushed between the 
index and middle fingers, forming a sac in which the tip 
of the tongue can rest. Grasping the tongue gently, but 
firmly, in this manner will allow of some manipulation, 
and the ring and little fingers resting against the chin will 
permit greater steadiness, and the tongue can be drawn for- 
ward without causing excessive resistance on the part of 
the patient. The mirror is held in a similar manner as for 




Fig. 39. Faulty position of patient's head and of 
the mirror. No laryngeal image obtained. 

rhinoscopic examinations, but with the reflecting surface 
facing downwards and forwards. The mirror is passed 
into the mouth and backwards until the uvula rests upon 
the back of the mirror, but care should be exercised not to 
touch the posterior pharyngeal wall. If the positions of 
the head and mirror are incorrect the probability is that 
only the dorsum of the tongue and lingual surface of the 
epiglottis will be seen, but with the disengag'ed fingers of 
the left hand, the head can be tilted backwards a little more, 
and depressing the handle of the mirror slightly, or pushing 
the mirror back a trifle, will bring the laryngeal structures 



94 



Nose, Throat and Ear. 



into view. If the patient will sound eh! several times it 
will aid by raising the larynx. The vocal cords can be seen, 
and in the act of phonation and inspiration can be seen ap- 
proximating and receding from the median line. 

It must be remembered in these examinations that the 
image is inverted. 

Clinically the larynx may be divided into three parts, 
the upper or supraglottic, or that portion above the ven- 
tricular bands; the glottic, which lies between the ventric- 
ular bands and vocal cords, including the ventricles, and 
the infraglottic which comprises the portion between the 
vocal cords and lower border of the cricoid cartilage. The 




Fig. 40. Position of vocal cords 
in phonation. 



FlG. 41. Position of vocal cords 
in inspiration. 



most conspicuous object seen in the examination is the epi- 
glottis, which on account of its form shows parts of both 
surfaces. The shape and position varies so much in differ- 
ent individuals that considerable experience is necessary 
to determine a normal from an abnormal cartilage. 

Behind the epiglottis and lower down, the diverging 
pearly white vocal cords are distinguished, passing back- 
wards to their attachment to the arytenoid cartilages. The 
Wrisberg and Santorini cartilages are seen as rounded 
swellings in the lower part of the image, forming in part 
the posterior boundary of the larynx, and between the 
arytenoid cartilages is the inter-arytenoid space. The ary- 



Examination. 



95 



epiglottic folds of mucous membrane pass from the ary- 
tenoid cartilages, on either- side, forward to the epiglottis 
( Williams). - 

The laryngeal examination should include normal and 
deep respiration and the movement of the cords during 
phonation which should reveal any abnormal movement or 
position. The color of the mucous membrane and the form 
of the various structures should be noted. The color of the 
epiglottis is slightly yellowish, the remainder of the laryn- 
geal tissues are a pale pink, excepting the vocal cords. It 
must be remembered that under the influence of the light, 
and possibly also the unusual muscular tension or vaso- 
motor changes during the examination, the color may 




Fig. 42. 
Adduction. 



Fig. 43. 
Respiration. 



Fig. 44. 
Abduction. 



Fig. 45. Cada- 
veric position. 



change rapidly from the pale anemic membrane to a posi- 
tive hyperemia. The vocal cords are pearly white or 
slightly tinged with pink. Persons who use the voice con- 
stantly or those with a bass voice, according to Williams, 
have the cords persistently reddened, and yet they are not 
abnormal. 

In some instances the sensibility of the larynx may have 
to be determined. This can be done by the use of a bent 
probe. If anesthesia of the larynx is present no especial 
reflex will be obtained, while in the normal larynx a vio- 
lent paroxysm of coughing will result. 

Many difficulties are encountered in making a laryn- 
goscopy examination, but they can usually be overcome by 



96 Nose, Throat and Ear. 

patience, it being well to remember that it is not always the 
fault of the patient. In some cases more satisfactory re- 
sults can be obtained by having the patient hold the tongue, 
which should be grasped between the fingers in such a man- 
ner as to keep the hand out of the way. This is important, 
as otherwise the patient's hand may interfere with the use 
of the mirror or any instrument used. In some persons 
there is such a hyperesthetic state that it is nearly im- 
possible to make a satisfactory examination. A few swal- 
lows of cold water may relieve this, or as a last resort, the 
surfaces can be sprayed with a solution of cocaine; or the 
auto-spray. 

Where for purposes of treatment repeated examinations 




Fig. 46. Pomeroy's Bar Syringe. 

are required, and the patient is not tractable, I have found 
by having them stand before a mirror, open the mouth and 
depress the tongue with a tongue depressor, or the, handle 
of a spoon, the sensitiveness usually soon passes off. The 
same rule will work in rhinoscopy. 

Otoscopy. — Instruments Required in Addition to Those 
Already Described. — A syringe is the most generally useful, 
and also the least liable to do mischief. Different styles are 
used, but where one does much ear work the capacity of the 
syringe should be not less than two ounces, and four ounces 
is more convenient in many respects. The soft rubber pus, or 
ear syringe will answer the purpose, however, in the major- 
ity of cases. Probes and cotton carriers should be light and 
some of them flexible. Ear specula of assorted sizes. For- 



Examination. 97 

ceps and curettes, in the hands of an expert, are necessary, 
but the novice should not attempt their use, and the expert 
only with good illumination. 

The anatomical relation of the ear to the upper respira- 
tory tract is conducive to extension of morbid conditions 
from the nasopharyngeal portion through the Eustachian 
tube to the middle ear, and as a result of this extension, it is 
absolutely necessary in treating the ear to have a definite 
knowledge of the morbid condition existing in the upper 
respiratory tract. This will in many instances determine 
the character of the changes which have taken place in the 
Eustachian tube and tympanum. 

After obtaining as complete a history of the patient's 
condition as possible, the examination should begin with 
an inspection of the auricle and adjacent parts. Abnormal 
or anomalous conditions should be noted. Inflammation of 
these structures, or redness over the mastoid. Pressure 
over the mastoid will often show tenderness, but a com- 
parison of both sides should be made, as hysterical patients 
will sometimes complain of pain when pressure over the 
mastoid apex is made, which is not the result of a diseased 
condition. The position of the auricles, whether symmet- 
rical or not. Redness and tenderness over the mastoid may 
be due to furuncles of the external meatus, or may be 
symptomatic of mastoid disease. With the head mirror in po- 
sition, and by means of an ear speculum the external audi- 
tory canal and membrana tympani should be inspected. 
\\ nen the membrane is ruptured, the middle ear may also be 
inspected. For minute inspection of the membrane, the view 
obtained by looking through" the aperture of the mirror is 
preferable, but in the majority of cases the mirror over the 
forehead will be satisfactory. The light should be on a 
level with the ear, and back of the patient far. enough so no 
discomfort from the heat is noticed. The style of speculum 
used is largely a matter of choice, but the Gruber pattern 



98 Nose, Throat and Ear. 

is most generally satisfactory. These may be either of 
metal or hard rubber. When a metal speculum is used it 
should be warmed. 

In introducing the speculum it should not be pushed 
forcibly into the canal, but held lightly by the thumb and 
index finger, and with a gentle rotary motion introduced 



»---"—:sSg 




Oo.o 

Fig. 47. Gruber's Ear Specula. 

into the meatus, not passing back far enough to reach the 
bony portion, which would cause pain. The speculum may 
be held in the left hand, the auricle grasped between the 
index and middle fingers and drawn outward, upward, and 
backward. When the physician is ambidextrous, the right 
hand would be used for holding the speculum for the left 
ear. The hairs in the meatus may be so numerous as to 
obstruct the view, but usually may be pushed aside with 
the speculum. Cerumen, scaly material, or any secretion 
which obstructs the view, must be removed, preferably by 
syringing. Care is necessary in properly introducing the 
speculum, as otherwise a view of the walls of the auditory 
canal are mistaken for the tympanic membrane, leading to 
a wrong diagnosis. There are a number of diagnostic 
specula, electrically lighted, etc., but very few of them are 
of practical use, excepting for obtaining a view of the mem- 
brane, as in all mechanical interference, resort to either 
the electric headlight or the mirror must be made. 

The appearance of the canal should be observed. The 
bony portion is, as a rule, of a pinkish tint, smooth, and 
glistening. In the examination there is often an annoying 



Examination. 



99 



reflex cough, due to irritation of the auricular branch of 
the pneumogastric nerve. 

Membrana Tympani. — The color of the normal mem- 
brane varies somewhat and the color described depends 
upon the color perception of the examiner, a translucent 
bluish white, or pearly tint, being the usual description. 
The color varies according to the light used, having a 
decidedly reddish yellow color when gas light of a yellow 
color is employed. In the normal ear the long handle of 
the malleus will be seen projecting downward and back- 
ward to the umbo or central concavity of the membrane. 
From the tip of the process extending downward and for- 




Fig. 48. Normal membrana tympani, right ear. (1) Membrane ; 
(2) handle of the mallens; (3) short process; (4) posterior fold; 
(5) anterior fold; (6) membrana flaccida; (7) triangular light spot. 



ward is a cone of light, the triangular light spot, extending 
nearly to the periphery of the membrane, the apex toward 
the tip of the handle. At the upper portion of the manu- 
brium will be seen the short process extending backward. 
Two folds of the membrane can be distinguished, the an- 
terior and posterior. The membrane above these is called 
Shrapnell's membrane, or membrana flaccida, and that be- 
low, the membrana vibrans. The color of the membrane is 
to be observed, whether normal, reddened, opaque, thick- 
ened, or atrophic, and as to opacities or cicatricial areas. 
The surface of the drumhead, retracted or bulging. If a 
collection of fluid is in the tympanum the membrane will be 
bulging, and the color changed according to the character 

Lore 



ioo Nose, Throat and Bar. 

of the fluid, which will impart its tint to the membrane. 
If retracted, the handle of the malleus will appear short- 
ened, the short process and the anterior and posterior folds 
more prominent, while the cone, or window of light, will 
be displaced, distorted, or only a portion of it visible. The 
mobility of the membrane may be determined by the Val- 
salvan method, by the use of a probe or by Siegle's pneu- 
matic speculum, where either rarification or condensation 
of the air in the canal can be obtained. The tip of the 
speculum should be covered with a piece of rubber tubing 
so as to fit the canal more accurately. This principle is 
one of the methods used of applying massage to the ear, 
but never should be employed without -a full view of the 
membrane. 

Examination of the Eustachian Tube and Middle Bar. — 
To determine whether the Eustachian tube is open or not, 
it is necessary to use Politzer's inflation, the Eustachian 
catheter, or the Valsalvan method. The latter is not to be 
recommended under ordinary circumstances, as the patient 
will in all probability employ it too frequently. The cathe- 
ter in some instances is the best method for determining 
the perviousness of the tube, but is not as generally em- 
ployed as formerly. In fact, inflation is no longer a routine 
rneasure, as where any inner ear disease is present, it almost 
invariably increases the difficulty. 

The diagnostic tube is an aid in determining the 
condition of the Eustachian tube. This tube is of rubber 
and from two and one-half to three feet long. Two tips 
are provided, one white and the other black. In this way 
the examiner always uses the same tip for himself. The 
one tip is placed in the patient's ear and the other in the 
surgeon's ear. When the ear is inflated, if normal, a dis- 
tinct click is heard ; if fluid is present in the tympanum, a 
bubbling sound will be noticed, and a perforation of the 
membrane will produce a hissing .or blowing sound, de- 



Examination. 



ioi 



pending upon the size of the perforation. If no air passes 
through the Eustachian tube nothing is heard. 

The Politzcr Method. — The patient is seated in a chair 
and directed to take some water and hold it in the mouth 
until directed to swallow. The physician, standing in front 
of the patient, or a little to one side, introduces the tip of 




Fig. 49. Diagnostic Tube. 

the Politzer bag into one nostril, and with the thumb and 
index finger closes the alse of the nose by pressing the. en- 
gaged side against the tip, and the opposite side against the 
septum. The patient being directed to swallow, the air 
bag is compressed during the act of deglutition. The sud- 







MAX WOCHER &"«ON, ClN.,04 



Fig. 50. Roosa's Tip for Air 



den condensation of air in the nasopharynx will force some 
air into the middle ear. The soft palate is also forced down- 
ward and a dull gurgling sound is heard, thus indicating 
that the various acts' have been simultaneously per- 
formed, but not necessarily that air has passed into the 
tympanum. Having the patient close the mouth and make a 



162 



Nosk, Throat and Ear. 



moderately forcible expiratory effort, keeping the lips 
tightly closed, however, will be found less objectionable to 
many, and besides there is less liability of swallowing air 
which is not always pleasant to the patient. Politzer has 
changed the water method by having the patient inspire 
either through a small rubber tube or the nearly closed lips. 
In the use of the catheter this inspiratory method will be 
found useful. The nasopharynx is closed, and through the 
action of the pharyngei and palati muscles, the Eustachian 
tube is more open. When secretion is present in the middle 
ear, the patient should incline the head forward and side- 
ways to facilitate the escape of the fluid to the pharyngeal 
opening of the tube. If there is a perforation of the mem- 




MAX WOCHER & SON, CIN., O. 



FlG. 51. Politzer's Air Bag. 



brane, any fluid present in the tympanum may be forced 
into the external auditory canal, but when no perforation 
is, present^ there is a possibility of forcing some of the se- 
cretion into the mastoid, thus producing mastoiditis. In 
young children, when the mouth is closed, it usually is not 
necessary to use any of these methods, and if the child 
cries, it renders the operation still more effective. 

Catheterization. — Catheters are made of hard rubber or 
silver, and several sizes should be obtained. The metal 
should be malleable as the curve often will have to be 
modified to suit the individual case: The hard rubber may 
be modified by carefully heating the part desired to change 
over the top of a gas or lamp chimney and moulding as 






Examination. 103 

desired. When cold the curve will remain. The tips of 
these instruments should be probe-pointed, and the double 
curved catheter of Blake is the most satisfactory. The 
guide ring or pin at the base of the catheter should be im- 
movable and may be on either the same or opposite side of 
the tip, but in line with it, so that the direction of the tip 
is always known by tlie physician. 

The two usual methods of using the catheter vary only 
in the latter part of the manipulation. With the patient 
seated and having the catheter warm and lubricated with 
a bland unirritating substance, the ring and little fingers 
are placed on the patient's forehead and the tip of the nose 
gently elevated with the thumb. Holding the catheter in 
the right hand, as a pen is held, introduce the tip of the 

© © (§> (5) * 



MAX WOCHER U SON, CIN.. O. 

Fig. 52. Eustachian Catheter. 



instrument into the nostril and pass carefully along the 
floor of the nose until the posterior wall of the pharynx 
is touched, then turn the tip about a quarter turn outward, 
where it will engage in Rosenmuller's fossa. Then draw- 
ing the catheter slightly forward, and slightly elevating the 
tip, it will be felt gliding over the posterior eminence of the 
tube. A slight manipulation, raising and turning the tip a 
little more outward will usually engage the mouth of the 
Eustachian tube, and the guide will practically be in a line 
with the external canthus of the corresponding eye. The 
base of the catheter can now be grasped between the thumb 
and index finger of the left hand and the catheter tip of 
the air bag slipped into place, and the air forced through 
the catheter and Eustachian tube to the middle ear, but 
care must be exercised not to use too much force in com- 
pressing the bag, for if the membrana tympani is thinned, it 



io4 



Nose, Throat and Kar. 



may be ruptured by this method. The other method is 
practically the same until the posterior edge of the hard 
palate is reached, which is known by the curved portion and 
tip dropping down, or it may be pushed back until it 
touches the posterior wall, as in the first method. Then 




FiG. 53. Vertical section of head showing Eustachian Catheter 
in position, (a) Inferior turbinate ; (b) middle turbinate ; (c) superior 
turbinate; (d) hard palate ; (e) soft palate ; (f) posterior pharyngeal 
wall; (g) Rosenmiiller's fossa; (h) posterior lip of orifice of the 
Eustachian tube. 



turn the tip inward, bringing it to the horizontal, which the 
guide will determine, draw the catheter forward until the 
curved portion engages the posterior edge of the septum, 
then by rotating the point downward and outward complet- 
ing a little more than a semi-circle, the point should engage 
in the mouth of the Eustachian tube. The inflation is com- 



Examination. 105 

pleted as in the first instance. The air bag and Eustachian 
tip should be connected by a piece of rubber tubing, as 
otherwise more or less motion will be imparted to the distal 
end of the catheter and cause the patient pain, if not an 
actual tearing of tissue. 

The direction sometimes given to 'Connect the catheter 
and air bag before introduction, renders the task more dif- 
ficult. In some cases there is difficulty in introducing the 
catheter on account of obstruction in the nasal cavity, one 
side only may be free enough to allow the instrument to 
pass without undue discomfort to the patient. In such 
cases, I have experienced little difficulty in inflating the 
opposite ear, and in nervous persons nearly always cathe- 
terize both ears without withdrawing the catheter. This 
requires Considerable experience, but it is simply a reversal 
of the position of the tip, and giving a slight inclination of 
the base of the catheter outward. The distance necessary 
to reach the opposite opening is not very great, and prac- 
tice will soon enable one to inflate either or both ears with- 
out withdrawing the catheter. 

Prior to inflation, the membrana tympani should be in- 
spected to determine both the color and texture. As stated, 
but little force should be employed, as if the membrana 
tympani is atrophic, rupture may occur. After inflation the 
Color of the membrana tympani will be changed. If it was 
white before, it will have a pinkish tint, especially along 
the handle of the malleus, and if the membrane was red- 
dened, the color will be intensified. Even in using the 
diagnostic tube it is best to examine the membrana tympani 
after inflation. In the Valsalvan method, or auto-inflation, 
the patient holds the nostrils closed, and closing the mouth 
firmly makes a strong expiratory effort, not allowing air to 
escape from either the nose or mouth. This forces the air 
in the nasopharynx through the Eustachian tubes into the 
tympanum. Inspection of the membrana tympani during 



106 Nose, Throat and £ar. 

this procedure may determine the mobility of the drum- 
head. Patients, however, are liable to practice the method 
with considerable frequency, thus producing relaxation of 
the membrana tympani. Congestion of the brain sometimes 
follows this method temporarily, and in persons with a 
weak or faulty heart action, alarming symptoms are some- 
times produced. Relaxation of the membrana tympani will 
also follow either catheterization, or the use of the Politzer 
bag, if continued for a considerable period, and although 
they have their place in aural practice, should not be used 
as a routine measure. 

Hearing Tests. — To determine the acuity of hearing is 
most important. In the different tests the seat of the lesion 
is usually determined, whether in the external, middle, or 
inner ear. Sound vibrations are recognized both through 
the air and the bones of the head, hence the necessity for 
different tests. The watch test is the one most frequently 
employed and also probably the most unsatisfactory. The 
loudness of tick varies with different watches, but the watch 
employed should be tried with different persons whose hear- 
ing is supposed to be normal. This distance will be the de- 
nominator and will usually be twenty-five inches to sixty 
inches. When the patient hears a sixty-inch watch at ten 
inches, it is expressed H. D. 10/60. The ear not under test 
should be closed, which may be done by having the patient 
moisten the tip of the index finger, press it against the ex- 
ternal meatus with force enough to close it. Having the 
patient close the eyes, hold the watch first so the ticking 
can be heard, as at times they do not readily understand 
what is required. Then hold the watch at the normal dis- 
tance, if not heard, move the watch slowly toward the ear 
until it is heard. The distance can easily be read on a tape 
measure, but if it is metal it should not be held against the 
bones of the head until the tick has been recognized. If 
the watch is held against the ear first and then moved away, 



Examination. 



107 



it will be heard at a greater distance ; however, I generally 
use both methods and compare results. If the watch is 
not heard until in contact with the ear, it is written C/60, 
C.= contact, and if it must be pressed firmly against the 
auricle P/60. P= pressure, if not heard even then the 
record would show 0/60. Of course the ear examined is 
designated as R. or L. D. or S., according to the individual 
preference. 

Acoumetcr. — Politzer devised an acoumeter which al- 




MAX WOCHER & SON. CIN., O. 



FiG. 54. Politzer's Acoumeter. 



ways gives a sound of the same intensity, thus having an 
instrument of more precision than the watch. The short 
lever can be depressed only a certain distance, so the ham- 
mer in striking the metal bar always falls with the same 
force. An attachment for testing the mastoid conduction, 
the temple, etc., consists of a metal rod with a round plate 
which rests against the bony portion to be tested. The 
hearing distance by air conduction is measured by the tape 
as with the watch. Another instrument sometimes em- 



io8 



Nosk, Throat and Ear. 



ployed, but of no value excepting for aerial hearing-, is the 
metronome. The intensity of this is such that it is difficult 
.to determine the amount of impairment, unless very marked. 
The hearing acuity should always be tested for speech, both 
whispered and ordinary conversational tones. The exam- 
iner should stand on the side, as otherwise the motion of 
the lips will furnish, a clew to many people, and the test 
will not be accurate. The distance from the patient should 




Fig. 55. Tuning Fork, Middle C. 

also be noted in these tests. Whispers, especially when the 
vowels are accented, can be ordinarily heard by the normal 
ear at fifty feet in a room that is perfectly quiet, but this is 
a condition not often obtainable in city practice. 

Tuning Forks. — For simple diagnostic purposes, a mid- 
dle C fork is all that is required, although the specialist 
should be provided with at least three, C. 128, C 2 -5I2, C 4 - 
2048 vibrations per second. The Blake fork, in which the 



MAX WOCHER & SON, OIN., O. 

Fig. 56. Blake's Tuning Fork. 



vibrations are produced by pressing the ends together with 
the thumb and index finger, will be most desirable where 
but one is employed. This fork always gives the same in- 
tensity, while in using the ordinary form it is difficult to 
strike the fork with the same force. It should be struck 
on the knee, and not on a hard substance, on account of 
the excessive overtones produced. Clamps are also pro- 
vided for controlling overtones. A fork with a percussion 



Examination. 109 

hammer is made which will allow of a uniform stroke. A 
Galton whistle is also useful, as the intensity of the note 
can he regulated. Koenig's rods are used, but excepting 
for the specialist, are not necessary. Low toned forks are 
heard better in labyrinthine disease, than high ones, when 
held close to the ear. When middle ear disease is present 
and hearing for speech is impaired, the same fork is faintly 
heard. 

In a normal ear, the tuning fork is heard most dis- 
tinctly when held close to the ear, A. C. best, but is quite 
indistinct when placed against the mastoid or bones of the 
cranium. In external and middle ear disease, the tuninsr 
fork is heard more plainly when placed against the bone. 




Fig. 57. Galton's Whistle. 

So the record would read, B. C. best; that is, bone con- 
duction best, always indicating the ear tested. In inner ear 
disease the fork is heard better through the air, but the 
hearing is impaired, and again the formula would read 
A. C. best; that is, aerial conduction best. The time the 
fork is heard through the air should be carefully noted, as 
in many cases where the defect is slight, or inner ear disease 
is just beginning, this will be the only positive method of 
determining the lesion. 

By inserting the finger tip in the external meatus, the 
sound is intensified in the abnormal ear, in middle ear and 
external ear disease when the test is made by bone conduc- 
tion, whether on the vertex, forehead, or the teeth, In 



no Nose, Throat and Ear. 

inner ear disease, bone conduction is nearly or completely 
destroyed. As a rule aerial conduction is better for the 
high note tuning fork in middle ear disease. 

Galton's whistle is of value in testing with high notes, 
the range is from about 3,000 to 50,000 vibrations per 
second. 

Koenig's rods, consisting of steel rods, produce vibra- 
tions from 10,000 to 40,000 per second, the intervals be- 
ing 2,500 vibrations. 

In old age bone conduction is diminished, Politzer 
claiming that it is seldom that a low ticking watch is heard 
through the cranial bones after the age of sixty. 

Rhine's Test. — Place the base or handle of the vibrat- 
ing tuning fork against the side of the skull or on the 
mastoid. As soon as the patient ceases to hear the vibra- 
tions, hold the blades of the fork close to the external audi- 
tory meatus, being careful, however, not to touch the ear. 
If the fork is again heard, it constitutes the positive Rhine 
test. The negative Rinne test is a reversal of this. 

Unless there is disease of the inner ear, these tests are 
especially valuable in otitis media when marked. 

Weber's Test. — This is a better test where the deafness 
is slight. Using the 512 V. S. tuning fork on the median line 
of the bones of the head, teeth, or lower jaw, it is usually 
not difficult to determine which side is most affected, as the 
fork is heard plainer in the side most affected. In rare 
cases there will be a difference of tone in the two ears. 
This may be the result of increased tension of the fluids in 
the inner ear through congestion or effusion, or by increased 
inward pressure of the stapes. 



CHAPTER IV. 
NOSE. 

Besides the primary functional relation of the nose to 
respiration, olfaction, and phonation, a secondary action is 
performed. In the respiratory act, it is not often that the 
unmodified external air would not be an irritant to the 
mucous surfaces of the lower respiratory tract, hence in 
passing through the normal nasal cavities it is prepared for 
entrance into the laryngeal and lower structures by modi- 
fied temperature, moisture, and more or less freedom from 
suspended foreign matter. After the inspired air has passed 
through the nasal cavities, the temperature will be found 
approximately blood heat when it reaches the larynx. This 
occurs whether the atmospheric temperature is warmer or 
colder than the body. 

The change in the nasal cavities is due, not only to the 
temperature of the nasal area, but also to the glandular se- 
cretion and the vapor exhaled from the lungs deposited 
upon the nasal tissue and maintained at the body tempera- 
ture by the vascular supply, especially in the erectile tissue. 
The larger floating foreign particles are arrested by the 
vibrissas, or short stiff hairs in the anterior portion of the 
vestibule, and the smaller particles are deposited and retained 
on the moistened mucous membranes bv the tenacious 
mucus. This mucus, with its accumulation of foreign ma- 
terial, is gradually moved forwards toward the nostrils by 
the movements of the ciliated epithelium, thus tending to 
keep the nasal surfaces free from detritus. 

The various theories of olfaction can be studied in the 
numerous works on physiology. 

in 



ii2 Nose, Throat and Ear. 

In vocalization, the condition of the nasal cavities exerts 
a marked influence on the quality of tone. When the nasal 
and post nasal spaces are clear, the full sonorous tones are 
present, but when there is obstruction in either or both of 
these cavities, the so-called ''nasal twang" is disagreeably 
present. Another factor in clear sonorous tones is the free 
movement of the velum. 

As accessory functions, free nasal cavities are important 
in hearing and tasting. In hearing it is necessary that the 
Eustachian tubes and their mouths be patulous. This per- 
mits of equalization of atmospheric pressure between the 
tympanum and the outer air, and also for the exit of the 
tympanic secretion. The naso-pharyngeal region, which is 
largely responsible for the condition of the tubes, is depend- 
ent upon the freedom of the nasal cavities. 

As regards the sense of taste, every one is familiar with 
the difficulty of distinguishing different foods when the nasal 
cavities are occluded, either by a severe cold or by holding 
the nostrils tightly and endeavoring to determine the char- 
acter of what is placed in the mouth. This does not apply 
to bitter, sweet, salt, or sour substances. 

The nose is also a sentinel in many cases, as it gives 
warning of poisonous or irritating vapors. It is also 
claimed by many that the mucus secreted by the nasal mem- 
branes possess a bactericidal influence. Many other at- 
tributes are supposed to be possessed by this organ, but 
they are simply theoretical, being as yet in the evolutionary 
stage. 

Mucous Membranes and Their Pathological Changes. 

The popular term "catarrh" is applied to all morbid 
changes in the throat and nose, and possess no significance 
as regards the pathological condition. The meaning of the 
word catarrh is, an exaggerated flow of secretion from the 
mucous membranes, especially applied to those of the nose 



Mucous Membranes. 113 

and throat. The name should, for the sake of conciseness, 
be discarded, unless used in its proper sense as a catarrhal 
inflammation, meaning increased secretion from mucous 
surfaces. 

There are many systemic diseases which will increase 
nasal secretion. Circulatory wrongs, vasomotor disturb- 
ances, or alteration of the character of the blood. Inter- 
ference of eliminative action of the kidneys, when the skin 
and mucous membranes may become vicarious eliminators. 
Congestion of the nasal and pharyngeal membranes often 
result from congestion of the thoracic or abdominal viscera. 
Chronic constipation and intestinal irritation frequently 
produce thickened and congested mucous membranes of 
the upper respiratory tract, and not infrequently the veins 
will present a varicosed appearance. Structural changes 
may result from long continued diseases of any of the 
viscera. 

As unrecognized systemic lesions may be the primary 
cause of disease in the upper respiratory tract, the impor- 
tance of an examination of the urine, as well as a careful 
examination of other organs should be considered. 

In many cases a nasal lesion is simply a manifestation of 
a primary disease of some of the accessory cavities, and 
will, unless care is taken in the examination, lead to a wrong 
diagnosis. 

A thin, watery, slightly albuminous secretion from the 
respiratory membrane is often found in marked cases of 
anemia. In children a similar exudate is often produced by 
intestinal irritation, resulting from the ingestion of indi- 
gestible material, or of intestinal parasites. 

The anatomical conformation of the nose also has a 
marked influence in rendering individuals susceptible to 
nasal lesions. Those persons who have narrow, slit-like 
nasal cavities, usually hereditary, are much more liable to 
nasal disease than those with well developed nasal cavities. 
8 



ii4 Nose, Throat and Bar. 

In the former class, the lumen or space between the turbinal 
and septal tissues is so slight that but little irritation or con- 
gestion is required to entirely close the nasal cavity, thus 
interfering not only with the respiratory function, but also 
preventing the free escape of secretion, which still more 
irritates the mucous membranes and ultimately produces a 
chronic type of rhinitis. 

The prevalent idea among the laity that a "catarrh will 
run into consumption" is untrue, but unquestionably neg- 
lected cases of long standing rhinal catarrhal inflammation, 
on account of the accumulation of secretion in the post- 
nasal space and posterior portion of the nasal cavities at 
night, and the unconscious swallowing of this secretion by 
the patient while asleep will produce a general catarrhal 
condition of the mucous membranes of the pharynx, larynx, 
as well as of the esophagus and stomach. This will lower 
the vitality, not only of these tissues, but of the general 
system as well, and when there is a tubercular tendency 
present, it may develop a true case of tuberculosis, but no 
disease, not tubercular, will develop a tubercular lesion. 

Mouth breathing not only causes a physiognomical de- 
fect, but eventually impairs the general health. This is 
especially true of children, as the nasal structures do not 
develop ; the child not only has a stupid look, but is actually 
stupid in mental work, and listless in play. Digestive dis- 
turbances soon appear, and the general health is much below 
normal. In children otherwise normal, mouth breathing 
indicates some obstruction to free nasal respiration, and 
should call for prompt relief. When neglected, not only the 
appearance of the face is changed, but the hard palate is 
often distorted, having a high irregular arch instead of the 
usual dome shape. 

According to Kyle, if the nasal floor or superior maxil- 
lary bone is thin from defective nasal respiration in early 
childhood or other causes, the terminal nerve filaments to 



Structure of Mucous Membranes. 115 

the teeth run superficially along the floor of the nose, and 
if a septal deflection is low down, and with redundant tis- 
sue, the inflammatory process injures the nerve roots and 
causes devitalized teeth, or may ulcerate, producing a sinus 
discharging around the tooth, simulating pyorrhoea al- 
veolaris. 

The shape of the bones of the nose, especially of the 
floor and turbinates, will markedly influence the drainage 
of the secretions either forwards or backwards, also the 
tendency to accumulation of solid foreign substances from 
the air. If the direction is backward instead of forward 
there is more tendency to rhinitic inflammation. 

Frontal headache and neuralgia and also facial neuralgia 
may result from either nasal disease or affections of the ac- 
cessory cavities. 

Some occupations appear to cause mouth breathers, as 
trainmen, motoimen, and engineers. In bicycle riders the 
tendency is also to keep the mouth slightly open, and the 
irritation caused by particles of dust coming in direct con- 
tact with the membranes of the pharynx and larynx often 
produces marked changes in the appearance of the struc- 
tures. 

Structure of Mucous Membranes. 

Nearly all diseases of the mucous membrane are in- 
flammatory, and the structure of this tissue should be well 
understood to intelligently understand the changes that 
occur, as well as for the treatment. 

Mucous membrane is composed practically of three 
layers : a, external, or epithelial cells ; b, basement mem- 
brane, which supports the epithelial cells : c, submucous con- 
nective tissue containing the blood vessels, lymphatics, and 
nerves. 

The epithelial portion varies in the character of the cells 
and the number of layers, according to location and func- 



n6 Nose, Throat and Bar. 

tion. In open cavities it is necessary that it should be soft, 
moist, and pliable. This is of the utmost importance in the 
nasal cavities, as the surfaces are constantly exposed to the 
drying action of the inspired air. As the character of the 
epithelial structure^ in this region is also protective, several 
layers are found, while in such places as require secretion 
only there is generally a single layer. The ciliated type of 
epithelium is found in all places where a protective or pro- 
pulsive force is required, as in the anterior nares and 
bronchi. 

Epithelial cells are miniature laboratories, in which the 
nutrition supplied is converted into mucus principally, and 
also according to location, chemical products. This being 
the case, it can readily be understood how morbid changes 
in the membrane will modify the product of the cells, and 
pervert the physiological action of the tissues, changing not 
only the chemical products, but also the character of the 
mucus, and retaining material that is both useless and detri- 
mental. The character of perversion induced largely de- 
termines the classification in diseases of the mucous mem- 
branes. 

The subepithelial layer, or basement membrane, furnish- 
ing nutrition to the epithelial cells, causes a change in the 
functions of the cells whenever any local or constitutional 
lesion affects it. This membrane is usually composed of 
two layers, although both may not always be distinguished. 
The external portion furnishes the material from which 
the epithelial cells reproduce themselves, and is called the 
genetic layer. In some cases this layer is absent, and if 
the epithelium is denuded, the surface is covered by growth 
from the margins. The lower layer of the basement mem- 
brane is constant, and consists of fibrous tissue, and pos- 
sibly may contain some unstriped muscle cells. The thick- 
ness of the basement membrane varies according to locality, 
in the nose and mouth being very thick, while in the alveoli 



Inflammation. 117 

of the lung it is almost invisible. The nerve fibers do not 
penetrate the membrane, but the lymphatics open by stomata 
immediately below or into the genetic epithelial layer. 

The submucous connective layer, or submucosa, is the 
important vascular portion, and varies considerably accord- 
ing to location. In the anterior part of the nasal fossae it 
constitutes the erectile tissue. Engorgement of this tissue, 
whether transitory or permanent, will diminish the lumen 
of the nasal cavities, causing much discomfort. In the 
female, engorgement of the erectile tissue is not infrequent 
during the menstrual period, and in both sexes this engorge- 
ment is not infrequent during sexual excitement. In an 
acute rhinitis (cold) this engorgement causes much discom- 
fort to the patient. 

Mucous membrane is not only a protective covering, a 
secreting membrane for mucus and other products, but it 
also possesses in a marked degree the property of absorp- 
tion when in a normal condition. This absorptive action 
depends usually upon the number of layers of epithelial 
cells. The health of the individual thus depends upon keep- 
ing the mucous membranes of the entire body in a healthy 
condition, as of necessity nutrition can not be maintained 
unless the mucous surfaces are kept moist, soft, and pliable. 
This can not be done unless these same tissues are perform- 
ing their normal functions of secretion. 

Inflammation. — A general consideration of inflamma- 
tion will assist in understanding the special changes which 
occur in mucous membranes. "Inflammation is the aggre- 
gate of those changes which take place in any tissue as 
the result of an injurious action to which it has been ex- 
posed, providing the injury is not sufficient to devitalize the 
part." 

It must not be inferred that the term injury always 
means trauma. It may be a direct 01 indirect irritation, 
(toxins) — local, constitutional, mechanical, thermal, or 



iiS Nose, Throat and Ear. 

chemical. Acute inflammation always presents definite 
changes, which may be classified as clinical or macroscopical, 
and microscopical. 

Clinical symptoms are subjective and objective, and di- 
vided into five clinical divisions — pain, heat, swelling, dis- 
coloration, and perversion of function. 

The microscopic changes, as the name implies, are found 
only by the aid of the microscope. These changes are 
usually described as : ( i ) Dilatation of the blood vessels 
with increased flow and accumulation of blood in the parts, 
followed by retardation of the current, as a result of the 
diminished caliber of the vessels through adhesion of the 
white corpuscles to the vessel walls, and paresis or paralysis 
of the vessels. As this condition increases, oscillation of 
the current results, followed by complete stasis (Kyle). 

Exudation into the perivascular tissue results before 
stasis occurs. After stasis the exudate is more marked and 
also tjiere is migration of the white corpuscles through 
ameboid movement. 

In a sudden and severe inflammation, there is migra- 
tion of the red corpuscles. Absorption of the exudate or 
proliferation of the fixed connective tissue cells and mi- 
grated corpuscles follows this process. If proliferation and 
nutrition is good, capillary budding results, and through the 
process of canalization, the tissue becomes vascularized ; 
but if nutrition fails, simple liquefaction-necrosis and ab- 
sorption may follow, provided no infection is present; but 
when infection is present suppuration occurs. The con- 
stant clinical stages are : ( I ) Change in the blood vessels, 
in the blood and its current — the intravascular, or clinically,' 
the dry stage ; (2) second or extravascular stage, exudate of 
liquor sanguinis and migration of white cells ; clinically, 
wet stage, properly exudative, as the exudate may be plas- 
tic (dry) ; (3) terminative, which depends upon nutrition 
and infection. 



Inflammation. 119 

These are the uniformly constant inflammatory mani- 
festations. 

By special inflammatory manifestations is understood 
those appearances which are found in different tissues, or- 
gans, parts, or oi a special disease or group of diseases. 

CLINICAL. MICROSCOPICAL. 

(1) HEAT 

f (/) Contraction^) 
(2) Dilatation. 
(j) Acceleration. 

(2) Sweeping. First Stage \ (4) Accumulation. 

I (5) Retardation. 
J (6) Oscillation. 
I (7) Occlusion. 



(3) Pain. 

f (8) Exudation {of 

, 4 ) DiS co l o RATI on. Skcoko Stag* #%£%?$ 

I corpuscles). 

[/o) Termination : 
(a) By r e so lu- 
tion ; 

(5) Disordered Function. Third Stage -j (b) By new for- 
mation ; 
(c) By sup pur a- 
[ Hon. 



The second stage usually determines the variety of in- 
flammation. (Kyle.) 

The types of inflammation of the mucous membranes 
pathologically considered as special forms are: (a) Ca- 
tarrhal, (b) Membranous — divided into croupous or pseu- 
domembranous, fibrinoplastic, and diphtheritic, (c) Hem- 
orrhagic, (d) Gangrenous, (e) Suppurative, (f) Chronic 
infectious. 

The varieties of rhinitis and pharyngitis nearly all orig- 
inate from these types. Constitutional diseases, infectious 
fevers, etc., causing lesions of the mucous membranes, 
properly come under one of the above varieties. 



i2o Nose, Throat and Ear. 

Catarrhal Inflammation. — Clinically an acute and 
chronic stage is recognized. Pathologically the resulting 
change is more or less due to acute processes merging by 
continuation of one of the stages into the chronic, or by 
repeated acute attacks. 

Acute Catarrhal Inflammation of the upper respiratory 
tract may result from a variety of causes, but the lesion is 
produced either by direct external irritation of the mem- 
brane, or is the result of disturbance of the circulation. In- 
fection is the most common factor in this condition. Ca- 
tarrhal inflammation of the upper respiratory tract is either 
concomitant or a sequel of acute infections as scarlet fever, 
measles, diphtheria, typhus, and typhoid fever. In the 
early stages of chronic diseases, as syphilis and tuberculo- 
sis, a similar condition is found. 

Under the classification of irritants a variety of causes 
may be named, exposure to cold, foreign bodies, hot air or 
steam, irritating chemical gases, ptomains, etc., sudden 
changes in temperature, excessive humidity, rapid changes 
in atmospheric pressure (caisson disease). The disturb- 
ance in circulation and secretion through these causes, pro- 
duces an inflammatory condition, lessening the resistance 
to exciting agents. This is true of nearly all irritants. Or- 
ganic changes in the lungs, liver, and kidneys; intestinal 
irritation with circulatory disturbances ; rheumatism, gout', 
and allied conditions may be either predisposing factors or 
actual causes of inflammatory states. Age also has an in- 
fluence, as in the adult the power of resistance is greatest, 
while in the young or the aged it is much lessened. 

A catarrhal stage is always present in inflammation of 
the mucous membranes. 

In the first stage of inflammation the surface is dry, and 
usually cov.ered with a thin layer of tenacious mucus. This 
results from the engorgement of the submucous vessels ob- 
structing the glands. Edema soon follows, caused by exu- 



Chronic* Catarrh ai. Inflammation. 121 

dation in the submucosa, and the tissues become swollen, 
presenting a more or less dusky red color. 

Infiltration of serum and leukocytes into the submucosa 
soon occurs after the engorgement of the vessels. Inter- 
ruption of nutrition to the epithelium causes this structure 
to become cloudy and swollen, desquamation following. 
There is huskiness of the voice, or even inability to articu- 
late above a whisper, as a result of the congestion of the 
submucous vessels. Nasal respiration is more or less im- 
peded through engorgement of the erectile tissue, the voice 
having the characteristic "nasal twang." 

The primary stage is generally of short duration, as an 
excessive amount of secretion soon appears. Rapid desqua- 
mation of the epithelial cells ensues and the surface is cov- 
ered with exudation consisting of degenerated cells, leu- 
kocytes, serum, and depending upon the cause and severity 
of the lesion, fibrin, and albumin. This exudative stage and 
also by the action of the lymphatics, usually diminishes the 
infiltration in the submucosa, and if the primary cause is 
removed, a normal circulation soon returns. Restoration of 
the epithelial layer results from the genetic layer. 

Ulceration is infrequent in this type of inflammation as 
the basement membrane is seldom affected. If it does, it is 
usually due to arterial thrombosis which causes localized 
superficial death by coagulation- and liquefaction-necrosis. 

Chronic Catarrhal Inflammation. — This is often the re- 
sult of neglected or repeated acute attacks. In many cases 
these acute attacks may be local manifestations of a constitu- 
tional disease, as syphilis, the impaired circulation of chronic 
heart disease, Bright's disease, rheumatism, gout, or so-called 
"malaria." Persistent local irritation may also be a cause. 
Organization of inflammatory exudate in the submucosa 
with proliferation of the fixed connective tissue cells will 
impair the nutritive functional activity of the mucous 
glands, producing the hypertrophic type of lesion. Contrac- 



122 Nose, Throat and Ear. 

tion of this adventitious tissue will lessen the blood supply 
to the epithelial layer and impair the function of the mem- 
brane. 

As contraction continues the lumen of the nasal pas- 
sages is increased, and an apparent hypertrophy results in 
atrophy, or as usually called "dry catarrh," as the secretion 
is much diminished. If the secretion is dry and tenacious, 
rendering removal difficult, decomposition often takes place 
and a marked fetor results; as in ozena. 

Membranous Inflammations. — Pathologically this type 
may be divided into; (a) croupous or pseudomembranous 
inflammation, the lowest grade of membranous exudate, 
consisting of a highly coagulable albuminoid material form- 
ing on the surface of the mucous membrane, without ulcer- 
ating or organizing. This may result from irritants as 
chlorine, ammonia, or escharotics, which do not devitalize 
the basement membrane. It may be found in infectious 
fevers, pyemia, and kindred conditions. 

(b) Fibrino plastic Inflammation is that form where a 
plastic exudation exists, and the tendency is to organization 
in layers or masses. This type is seldom found except 
in the nares. 

(c) Diphtheritic Inflammation. — This begins as a ca- 
tarrhal inflammation, and is generally ascribed to the Klebs- 
Loffler bacillus, or bacillus diphtheria. There is death of 
the superficial epithelial elements, and changes in the deeper 
cells of the mucosa. Coagulation-necrosis, or hyaline trans- 
formation of the diseased cells is the secondary change, 
transforming nearly all the dead cellular elements into hya- 
line material. The foci of degeneration and death starting 
on the epithelial surfaces and penetrating the tissue is char- 
acteristic of diphtheria. 

Removal of the membrane exposes a bleeding surface, 
due to ulceration or destruction of tissue, involving the base- 
ment membrane, or, as a result of interference of nutrition 



Gangrenous Inflammation. 123 

in the submucosa, infective coagulation-necrosis or slough- 
ing occurs. Fibrous tissue formation and contraction fol- 
lows, and if healing takes place only a partial or else no re- 
formation of epithelial surface results. 

Hemorrhagic Inflammation. — This variety of inflamma- 
tion seldom affects mucous membranes, but when it does it 
generally is in virulently infectious conditions, as anthrax, 
pyemia, septicemia, and* diphtheria. It has also been known 
to follow the application of a counter-irritant, as carbolic 
acid. The inflammation of the mucous surface in this type 
is rapid and there is interstitial hemorrhage. There is ob- 
struction of the capillaries supplying the area, and blood 
may ooze onto the surface of the epithelium. Gangrene is 
liable to occur if the area is small. In hemorrhagic in- 
flammation there is destruction of tissue with resulting 
cicatrization, while in simple purpuric interstitial hemor- 
rhage, absorption occurs without destruction of mucous 
membrane. 

Gangrenous Inflammation. — Most frequently seen in de- 
bilitated children following an acute infectious disease, 
usually measles.. Burns, scalds, or trauma of the mucous 
surface may also cause this type of inflammation. An em- 
bolus depriving a limited area of its blood supply may be a 
factor. Toxic doses of mercury, arsenic, or antimony may 
prove exciting causes. Diphtheria is a common cause. No 
matter what the cause of this form of inflammation, there 
is a cutting off of the blood supply to the part, and coagula- 
tion-necrosis and gangrene is the result. The tissue breaks 
down through infection, whether primary, secondary, or 
multiple. As more or less involvement of the submucosa 
is present, the lymphatics are distended and absorption of 
toxic material results, eventually producing a general sep- 
tic condition. Hemorrhage, as a result of the breaking 
down and infection of the thrombi, may result. Enlarge- 
ment or suppuration of adjacent lymphatic glands may oc- 



124 Nosk, Throat and Kar. 

cur, or septicemia result from general infection of the blood 
supply. Gangrenous inflammation is frequent in the ton- 
sils, mouth, and pharynx, but infrequent in the nose. 

Suppurative and Pustular Inflammation. — This may be 
seen during septicemia, pyemia, chicken-pox, small-pox, or 
erysipelas of the mucous membrane, but seldom in other 
infectious diseases. In diphtheria, mixed infection may pro- 
duce pus in the submucosa. Infection of the submucosa 
may follow an abrasion or destruction of the epithelial sur- 
face. The pouring out of infected material into the sub- 
mucosa produces distension and pus formation. Suppura- 
tive tonsilitis is a familiar type of this condition. Pus, now 
conceded as a product of connective tissue, forms in the 
submucosa, and escapes by rupturing the basement mem- 
brane by a gangrenous or ulcerative process. Dissemina- 
tion of the material by the lymphatics may occur, when a 
gangrenous type of inflammation will result. 

Specific Inflammations. 

Synonyms. — Chronic infectious inflammations : Specific 
granulomata; Chronic specific inflammatory processes; In- 
fectious granulomata. 

There are six varieties of specific inflammatory pro- 
cesses: (i) syphilis; (2) tuberculosis; (3) actinomycosis; 
(4) glanders; (5) leprosy; (6) rhino-scleroma. 

(1) Syphilis. — Usually the initial lesion of syphilis is 
the mucous membrane. At the point of infection infiltration 
of the mucosa with small, round epithelioid and giant cells 
occurs. Through obliterative changes in the, arteries, the 
superficial blood supply is destroyed, causing ulceration. 
The tongue, gums, cheeks, tonsils, palate, or pharynx may 
show these diseased spots. In the tertiary stage gummata 
may develop, and pass through the same ulcerative process 
in the mucosa as any of the infectious granuloma. The 






Specific Inflammations. 125 

amount of fibrous tissue developed in the healing process 
produces considerable contraction. 

(2) Tuberculosis. — Primary tuberculosis of the upper 
respiratory passages may occur, but usually it is secondary 
to pulmonary lesions. The tubercle bacillus is considered 
the cause of tuberculosis, and by gaining an entrance to 
some portion of the mucous membrane, miliary tubercles 
develop around the vessels of the submucosa. The morbid 
process extending from these points, necrosis and ulcera- 
tion of the tissues follow. Through the ulcer thus formed, 
the tubercular caseous material is exuded. New fibrous 
material may form around the ulceration, which in contract- 
ing will cause stenosis. 

(3) Actinomycosis. — This is a common lesion in the 
mouth, caused usually by an abrasion of the mucous surface 
affording a nidus for the ray fungus, or actinomyces. Gen- 
erally introduced into the system with the food. The de- 
veloped granulation tumor is similar in structure to tuber- 
cule. The surrounding zone of proliferating tissue gener- 
ally resembles sarcoma. Suppuration through mixed in- 
fection results. . The presence of the ray fungus in the se- 
cretion or tissue determines the disease. 

(4) Glanders. — The Bacillus Mallei is the factor in 
this disease, which makes its appearance usually in the form 
of ulcers in the nose. The ulcerative process is similar to 
the forms of inflammation already described. When acute, 
gangrenous and septic conditions may result. When chronic, 
the ulcers do not differ in appearance from those of tuber- 
cular, syphilitic, or of long-continued catarrhal conditions. 

A differential diagnosis is made by the presence or ab- 
sence of the bacillus mallei in the discharge. It may be 
mistaken for sarcoma. 

(5) Leprosy. — Infrequently seen in the upper respira- 
tory tract, but may attack the nose or larynx. Generally of 



126 Nose, Throat and Ear. 

the tubercular variety. Ulceration does not always occur. 
Bacillus Leprae is the cause of this disease. 

(6) Rhinosci^roma. — This infrequent inflammatory 
type is characterized by a thickening and tumefaction of 
the nasal mucous membrane. The larynx may be the point 
of attack. The microscopic appearance seems allied to the 
round-celled sarcoma, but small, highly refracting hyaline 
bodies are present which are a characteristic element of the 
growth. The areas of tumefaction present first a pink or 
red color and are quite sensitive. Later the tissue becomes 
white. Seldom seen in this country. The cause of the dis- 
ease is obscure. The condition is chronic. 

Nasal Bacteria. 

The question of whether the majority of bacteria are 
primary or secondary to nasal lesions, is a disputed point. 
When through faulty anatomical formation of the nasal 
cavities, there is a condition. present which favors the ac- 
cumulation of dust or secretion ; lowered vitality, with the 
consequent lessened power of resistance through systemic 
diseases or organic lesions ; and the changed character of 
the secretion, forms a better culture medium for these 
germs, is still a question for the future to decide. Some 
claim the normal nasal secretions are inimical to the life of 
these organisms. What constitutes a normal nasal mucous 
membrane? Normal functional activity may be present, 
but through faulty anatomical construction, this normal se- 
cretion may accumulate in one or both nasal passages, form- 
ing an obstruction which will retain dust and other irritat- 
ing material, causing local changes in the tissue, perverting 
the secretion of the area, and forming good culture media 
for the bacteria which are constantly inhaled. 

The normal secretions do not form a suitable media for 
the cultivation of these organisms, and although they are 
generally, if not always, present in the secretions, they do 



Nasal Bacteria. 127 

not multiply rapidly and are not considered of any special 
pathognomonic importance. The bacteria found may be 
the so-called pathogenetic variety, but non-virulent, and as 
long as the mucous membrane retains its normal charac- 
teristics, they are practically benign. The vocation and en- 
vironment of a person has a marked influence on the kind of 
micro-organisms found. 

Among many of" the most conservative investigators 
these bacteria are believed to be secondary to the disease, 
infection of the mucous membrane being brought about by 
external or internal irritants which have lowered the vitality 
of the individual epithelial cells. Varieties of biastomy- 
cetes are also present and may be factors of irritation, with- 
out being in themselves pathogenic. 

In rhinitis when there is an accumulation of secretion, 
which is difficult to dislodge, there will be found such a 
variety of bacteria that no special variety can be designated 
as an etiological factor. The bacteria of decomposition are 
always present, saprophytic bacteria. The products of these 
scavengers are being constantly absorbed by the mucous 
membranes, and often may account for some of the symp- 
toms observable as regards the general health in advanced 
stages of rhinitis. The 'unconscious swallowing of the in- 
fected secretions of the naso-pharynx and pharynx during 
sleep often causes gastric lesions, diseases of the upper 
respiratory tract and the stomach being frequently asso- 
ciated. Neither of these lesions in all probability would 
have developed had the epithelial structures been in a nor- 
mal condition. 

The bacteria found on the mucous membrane of the 
nose and in the secretion includes many pathogenic cocci 
and bacilli, as well as numerous unclassified non-pathogenic 
germs. Staphylococci, or micrococci, are most generally 
found, especially staphylococcus pyogenes aureus, citreus, 
and albus. Micrococcus pneumoniae (Frankel). Bacillus 



128 Nose, Throat and Ear. 

tuberculosus, Friedlander's pneumococcus, Klebs-Loffler 
bacillus, Von Hoffman's bacillus (bacillus of pseudodiph- 
theria), Bacillus fcetidus, Loewenberg's ozena diplo- 
coccus and different forms of sarcina. Any of these 
may be found at times, even when not associated with 
inflammatory conditions, and are nonvirulent, as shown by 
the Escape of the individual from any illness. 



CHAPTER V. 

ANOMALIES AND THE RELATION OF 

GENERAL DISEASES TO THE 

UPPER RESPIRATORY 

TRACT AND EARS. 






ANOMALIES OF THE UPPER RESPIRATOR^ 
TRACT. 

Nose. — Absence of. — As a congenital condition this is 
rare. Maisonneuve reports a case where a plane surface, 
perforated by two small openings, occupied the site of the 
usual nose. Exaggeration of size is not infrequent, the most 
noted of which we have a record, being a nose seven and 
one-half inches long. 

Congenital Division of the Nose. — A few cases have 
been recorded of double noses. 

Congenital occlusion of the anterior nares, as well as of 
the posterior nares have been reported. A central depres- 
sion of the tip of the nose is sometimes seen, and is analo- 
gous to hair lip. 

Of the palate, fissures, which may be unilateral, bilateral, 
median, etc., are usually associated with hair lip. 

Uvula. — The uvula may be bifid, double, and is some- 
times absent. . 

Epiglottis. — A few cases are recorded of absence of 
the epiglottis, and one case of bifurcated epiglottis is re- 
ported. Duplication of the epiglotti's is reported in several 
cases. 

Congenital web of the vocal cords has been found in a 
few cases. 

9 i 2 9 



130 Nose, Throat and Ear. 

General Symptomatology. 

Not only a thorough knowledge of special manifesta- 
tions and general diseases is necessary in studying special 
branches of medicine, but plenty of good sense and judg- 
ment are requisites, for without the latter qualifications ir- 
reparable damage may result from bigoted views regard- 
ing local symptoms or abnormal conditions. It is always 
better to discover that a seemingly local manifestation is 
reflex before resorting to heroic measures, than to find later 
that what has been done is not only useless, but positively 
harmful. Fads in operative work should have no place in 
treating diseases of the ear, nose, or throat, and the tendency 
now is to conservatism in this line of work. Systemic 
treatment is being more and more insisted upon and less 
reliance placed on local measures only. The fact that the 
use of sprays, etc., are only of value for cleansing purposes 
and are of no value as curative agents, marks an advance 
in treating these parts, that is satisfactory to both physician 
and patient. 

Disturbances of the upper respiratory tract and often of 
the ears, are frequently seen as a result of constitutional 
lesions, so a brief resume may be helpful. Chronic pul- 
monary diseases are sooner or later followed by chronic 
laryngeal and pharyngeal lesions. Croupous pneumonia is 
frequently followed by laryngeal complications, and in some 
instances even ulceration of the cords. Paralysis of the 
larynx is a not infrequent complication of diseases of the 
lungs and pleura, through the recurrent laryngeal nerve. 
Mediastinal tumors most frequently affect the left inferior 
laryngeal nerve. In enlargement of the thyroid, paralysis 
of the vocal cords may result, depending more upon the 
position of the hypertrophy than its size. Circulatory dis- 
turbances often affect the upper respiratory tract, producing 
hemorrhages, hyperemia or congestive conditions. Edema 



General Symptomatology. 131 

of the larynx is not infrequent in cardiac lesions which 
produce general edema. Paralysis also occurs in cardiac 
disease. Aneurysm of the aorta may produce laryngeal 
complications. 

The Digestive Tract. — Caries of the teeth may pro- 
duce antral disease and also rhinitis. Intestinal irritation 
and cirrhosis of the liver often are accompanied by nasal 
and pharyngeal symptoms. Gout and rheumatism affect the 
pharynx and larynx. The symptoms may pirecede the at- 
tack, be coincident with it, follow, or especially the rheu- 
matic type, may be the only manifestation of the disease. 
It is often difficult to make a diagnosis by the appearance 
of the tissues alone, but the character of the symptoms com- 
plained of should usually lead to a correct diagnosis. 

In acute and chronic infectious diseases, the implication 
of the upper air passages is so frequently seen and looked 
for, that they will not be considered excepting under the 
proper headings. 

Kidney Diseases. — Edema, hemorrhage, and general 
nutritive changes in the mucous membrane, are the usual 
complications. Edema of the uvula, posterior pillars of the 
fauces and lateral pharyngeal walls is most frequent. It 
is quite constant m the ary-epiglottic folds, and may be 
unilateral or bilateral. The edema is passive, resulting 
from venous stasis. An apparent laryngeal stenosis may 
occur in uremic conditions, but may be recognized by the 
fact that it appears periodically in persons with normal 
respiration. Hemorrhages in chronic interstitial nephritis 
are of frequent occurrence, and may occur in the nose as 
well as in the larynx. 

Sexuae Conditions. — Turgescence of the erectile tissue 
of the nose occurs during sexual excitement, and at the 
period of puberty. The same condition, more or less 
marked, often occurs in the female at the menopause, dur- 
ing menstruation and pregnancy. In diseases of the repro- 



132 Nose, Throat and Bar. 

cluctive organs, the vascular system is usually the medium 
through which the phenomena are manifested, there may be 
hyperemia, swelling, exudation or hemorrhages in the 
mucous membrane. According to Fliess, certain points on 
the anterior extremity of the middle and inferior turbinates 
and the septal tubercle are genital areas, and a beneficial 
influence over morbid conditions in the female can be ex- 
erted by treating these areas. It is claimed that cocainizing 
the genital areas will relieve the pains of menstruation; 
minimize labor pains, and that cauterizing these areas will 
cure dysmenorrhea. The "change of voice," especially in 
boys, which occurs at puberty is well known. Congestion 
of the mucous membrane is frequent and the voice "tires" 
easily. Similar conditions occur during menstruation, preg- 
nancy, and some uterine affections. The change in the 
character of the voice at puberty is the result of the phys- 
iological change in the increased size of the larynx. 

Paresthesia and hyperesthesia as a result of sexual in- 
fluences manifest themselves by dryness of the throat, a 
sensation as of a foreign body or desire to cough. This 
may result from hyperemia, but is more probably induced 
by the irritable condition of the nervous system at these 
times. 

Syphilitic phenomena are common, and will be de- 
scribed in full under their appropriate headings. 

Nervous Diseases. — In tabes dorsalis the olfactory 
nerve may be affected, and unilateral anosmia, parosmia, 
and olfactory hallucinations may exist. Laryngeal symp- 
toms may be present, the most frequent being motor palsies 
of the laryngeal muscles. The typical palsy being of the cri- 
co-arytenoideus posticus, one or both sides may be affected. 
The symptoms in the various forms of paralysis may be 
very marked or so slight that they are not noticed by the 
examiner, unless a careful laryngoscopy examination of the 
patient is made, especially in unilateral paralysis of the 



Neuroses. 133 

posticus. Complete paralysis of the recurrent nerve is in- 
frequent in tabes dorsalis. Laryngeal palsies are frequently 
seen in the earlier stages of tabes dorsalis and occasionally 
are the earliest symptoms. 

Multiple Sclerosis. — Multiple cerebro-spinal sclerosis 
produces a number of motor disturbances of the larynx. 
One peculiarity of the tremulousness of the vocal cords is 
that it occurs only during phonation, thus differentiating 
from other diseases, when the tremulousness is seen in 
phonation and respiration. 

The important symptoms in multiple sclerosis are : Re- 
tardation of muscular movements, and tremulousness of the 
cords. Fatigue of the muscles in speaking. Inability to 
sustain one tone for any length of time, as the irregularity 
of movement of the cords will produce high-pitched ex- 
plosive sounds. Incomplete tension and adduction of the 
cords, giving a rough, hoarse quality of tone. Muscular 
palsies are infrequent, the adductors are more often af- 
fected than the abductors. 

Medulla Oblongata. 

Syringomyelia. — Either in the initial or later stages, 
motor disturbances of the larynx and diminished reflex irri- 
tability of the posterior pharyngeal wall may be found. 

Neuroses. 

Paralysis Agitans. — Motor disturbances of the cords 
occur, which affect the quality of the voice and of speech. 
Twitching movements of the cords in phonation and usually 
in respiration are present. The epiglottis and uvula may 
also be tremulous. 

Epilepsy. — Gottstein gives as a constant accompani- 
ment of the epileptic seizures, anesthesia of the laryngeal 
mucous membrane, which may persist for sometime after 



134 Nose, Throat and Ear. 

the attack. Disagreeable olfactory sensations often consti- 
tute an epileptic aura. 

Hysteria. — In this disease, the effects produced on the 
mucous membrane and functions of the upper air passages 
are about as varied as are the manifestations of the general 
symptoms. 



CHAPTER VI. 

DISEASES OF THE ANTERIOR 
NASAL CAVITIES. 



ACUTE INFLAMMATORY DISEASES. 

Acute Rhinitis. — (a) Simple acute rhinitis, (aa) In 
children, (aaa) Acute rhinitis in systemic diseases, (i) 
Measles. (2) Pertussis. (3) Scarlet fever. (4) Small-pox. 
(5) Typhoid fever. (6) Rheumatism. (7) Diabetes Mel- 
litus. (8) Diphtheria. (9) Erysipelas. (10) Scorbutic 
Rhinitis. (11) Anemic Rhinitis. (12) Scrofulous Rhinitis. 
(13) Caseous Rhinitis. (14) Epidemic Influenza. 

(b) Menbranous Rhinitis. — (1) Croupous or Pseudo- 
membranous. (2) Fibrinoplastic. (3) Diphtheritic. 

(c) Occupation Rhinitis (Traumatic), (d) Hyper- 
esthetic Rhinitis (Hay Fever) See Neuroses, (e) Ulcera- 
tive Rhinitis, (i) Edematous Rhinitis (Acute Edema), (g) 
Phlegmonous Rhinitis. 

Simple Acute Rhinitis. 

Synonyms. — Acute Coryza ; Acute idiopathic rhinitis ; 
Acute nasal blennorrhea ; Acute nasal catarrh ; Acute rhinor- 
rhea ; Catarrhal rhinitis ; Cold, or cold in the head ; Common 
sporadic catarrh ; Rhinitis catarrhalis ; Simple catarrh ; 
Snuffles. 

In temperate climates this is the commonest of all 
diseases. 

Etiology. — Predisposing Causes. — The most prominent 
of predisposing causes is impaired vitality of the entire sys- 

135 



136 Nose, Throat and Ear. 

tern. This condition is found principally among those who 
are most of the time indoors, the rooms being overheated, 
or subjected to variable temperatures. Prolonged mental 
strain by enfeebling the nervous system will also prove an 
important factor. Abnormal development of the nasal cav- 
ities, as deflections of the septum or narrow cavities. Hered- 
ity may be a factor in predisposing to this disease. 

Among chronic lesions which may have an influence, 
may be mentioned syphilis, rheumatism, tuberculosis, 
asthma, or hay fever. In women of a nervous constitution 
it sometimes is present at the menstrual period. Improper 
clothing may be a cause. That temperature and climatic 
conditions have an influence is certain, as this disease is 
much more frequent in those localities where extremes in 
temperature and moisture are common. Sexual excess is 
also a predisposing factor. In some instances the only ex- 
planation is an idiosyncrasy. In old age the disease is com- 
paratively infrequent. 

Exciting C ses. — Chilling of the body, either from ex- 
posure to draughts, damp or wet feet, or sitting in damp 
clothing. Going from either overheated rooms into cold 
rooms or from cold into overheated rooms, or excessive ex- 
ercise may be factors. In many of the infectious diseases, 
as measles, scarlet fever, influenza, etc., it is nearly always 
present. It sometimes accompanies gastric, or intestinal 
irritation, or may follow a sudden cessation of the discharge 
m suppurating middle ear disease, or gonorrhea. It may 
also be a result of laryngeal, pharyngeal, conjunctival, or 
accessory sinus .inflammation, or be associated with eczema 
or impetigo. 

At times it appears to be epidemic, through climatic con- 
ditions. Insufficient sleep is also a factor. 

Occupation has a marked influence in many cases. Per- 
sons working in places where they are inhaling irritating 
dust or vapors, which includes persons handling irritating 



Simple Acute Rhinitis. 137 

drugs and chemicals, stone-cutters, cement workers, bronze 
workers, millers, weavers, and threshers. These forms of 
inflammation might be classed as traumatic or occupation 
rhinitis. 

Tumors in the nasal cavities or the introduction of for- 
eign bodies will also produce an acute rhinitis. The inges- 
tion of some drugs will have an irritant effect on the mucous 
membrane as the iodides, arsenic, etc. 

Pathology. — The pathology is practically that of a sim- 
ple catarrhal inflammation. If the attack is the result of a 
cold, the temperature of the exposed surface is suddenly 
brought ' below normal. The irritation of the peripheral 
nerves of the portion of the body chilled causes, by trans- 
mission, a corresponding influence on the sympathetic, 
reaching the vasomotors of the nasal mucous membrane. 
The first result is contraction of the vessels, rapidly followed 
by dilatation. It is usually supposed that rhinal inflamma- 
tion invariably begins on the superior surface of the middle 
turbinates, extending in all directions from these foci. The 
membrane is tumid, dark red in color and the vessels in- 
jected. In the initial stage there is little or no secretion, 
the surface being dry or covered with a thin coating of te- 
nacious mucus. When dilatation of the vessels occurs 
through vasomotor paresis, there is an exudate of serum 
into the submucous tissue, migration of white cells and 
more or less escape of red corpuscles. At the same time 
there is an exudation of an irritating, saline • laden, clear 
limpid serum on the surface. The epithelial cells being 
more or less deprived of their nutrition, become cloudy, 
swollen, die, and are carried off with the secretions. This 
material and the leukocytes mixing with the mucus and 
serum soon forms a profuse, cloudy, thick, more or less puri- 
form secretion depending upon the proportion of the cellu- 
lar elements. If the inflammation is very severe, there may 
be small ecchymoses, or even minute abrasions or erosions. 



138 Nose, Throat and Ear. 

When there are no complications, the vessels gradually re- 
sume their tonicity, absorption of extravasated elements 
occurs, the exudation upon the surface diminishes, thickens, 
and eventually ceases, new epithelial cells are developed 
from the genetic layer, and the tissues resume their normal 
functions. 

If the disease is the result of direct irritation by median-' 
ical or chemical irritants, the glandular elements are prob- 
ably affected first, and, becoming engorged, act as foci for 
the pathological process/ 

Symptoms. — The attack is usually sudden, and often is 
preceded by a feeling of general lassitude and discomfort. 
There may be an initial chill, especially when the attack is 
severe. A tingling or tickling sensation in the nose ap- 
pears early in the attack, and generally causes more or less 
sneezing. Often there is a dry, burning, or full feeling in 
the nose or head ; a cold sensation in the region of the frontal 
cells; dull, throbbing frontal or occipital headache; cold- 
ness or stiffness of the back of the neck ; malaise ; burning 
of the eyes, and fever. In a short time the sensation of 
stuffiness in the nose becomes aggravated, and the nasal 
respiration is obstructed. Impairment of the senses of 
smell and taste, and often, through implication of the Eu- 
stachian tubes, of hearing, is noticed. A "nasal twang" is 
imparted to the voice through the nasal obstruction. There 
may be considerable disturbance of the general system, but 
this is the exception. 

Inspection of the anterior nares in the first stage reveals 
a swollen, dry, or glazed mucous membrane, varying in 
color from a slight to a dark red, depending upon the 
severity of the attack. The nasal cavity may be occluded 
by the turgescence of the tissues. As the disease progresses 
the skin becomes dry and hot ; thirst, anorexia and a furred 
tongue may follow. The nasal secretions may remain clear, 
or become puriform, and are often very irritating or exco- 



Simple Acute Rhinitis. 139 

riating. The alse of the nose and upper lip are swollen, red- 
dened, or excoriated. The eyelids become swollen and there 
is increased lacrimation, and occasionally photophobia. As 
the severity of the symptoms subsides, there is a tendency for 
the secretion to fill the respiratory portion of the nasal cavi- 
ties, leaving the upper spaces clear. The secretion becomes 
thicker and more opaque during the progress of the second 
stage. Constipation and high colored urine usually fol- 
lows in severe cases. 




Fig. 58. Normal left nasal cavity, (a) Superior turbinate; 
(b) middle turbinate; (c) inferior turbinate; (d) Eustachian opening; 
(e) velum; (f) uvula; (g) post-nasal space; (i) vestibule; (j) sphenoid 
sinus; (k) frontal sinus; (o) Rosenmiiller's fossa. 

Inspection during the second stage reveals the tissues 
swollen, deep red and bathed with the mucus or muco- 
purulent secretion. The second stage gradually merges 
into the third or last stage, the symptoms disappear and 
there is restoration of the tissues to approximately their 
normal state, if recovery is the termination. The attack, if 
allowed to pursue its course, lasts for a week or ten days. 

The acute rhinitis due to irritants, etc., usually runs a 



146 



Nose, Throat And Ear. 



shorter course, and is devoid of die constitutional disturb- 
ances, removal of the exciting cause usually resulting in 
a speedy cure. 

Course. — The length of time required to effect a cure 
will depend upon the severity of the attack and the time that 
has elapsed between the initial stage and the time the case 
is seen. When seen early the disease can usually be aborted, 




Fig. 59. Appearance of nasal cavity in an acute rhinitis. 



but if in the second stage, more time will be required to 
effect a cure. 

Diagnosis. — Generally not difficult, but care should be. 
exercised, as an acute rhinitis is often a symptom of more 
severe systemic disorders. 

Prognosis. — Generally favorable in uncomplicated cases. 
In the aged, or in debilitated subjects, the liability of com- 
plications must be remembered. A chronic condition may 
result, especially in those who are subject to repeated at- 
tacks. 

Complications. — These, as a rule, are not serious, but 



Simple Acute Rhinitis. 141 

implication of the accessory cavities, nasal ducts, or Eu- 
stachian tubes, or extension of the morbid process to the 
pharynx and larynx, may cause some chronic lesion. 

Treatment. — For controlling the morbid condition, the 
employment of constitutional remedies will give far better 
results than local measures. The use of cocaine, or the 
suprarenal derivatives, while in many instances affording 
temporary relief, will in the reaction, produce not only 
more engorgement of the tissues, but also in many cases 
permanent relaxation. The danger of inducing the cocaine 
habit must also be remembered, and if used, the patient 
should be kept in ignorance of the drug employed. In my 
experience better results are obtained by systemic medica- 
tion. For relief of the sneezing, stearate of zinc with euro- 
phin has sometimes been a useful local application. The 
employment of various medicaments in oily solutions has 
been disappointing, excepting for temporarily lubricating 
the tissues. 

If the patient is seen in the early stages, especially when 
the weather is warm and depressing, aconite and gelsemium. 
An acrid, watery secretion with erysipetalous redness of the 
alse and tip of the nose, and chilly sensations, belladonna. 
With a thin watery secretion, non-excoriating, dist. ham- 
amelis. If the discharge is thin, watery, and excoriating, 
liquor potassii arsenitis. The discharge moderately profuse 
and thick, Hydrastis. If the secretion is tough, tenacious, 
and stringy, potassium bichromate. When the nasal pas- 
sages are alternately open and closed, especially if the 
pharyngeal structures appear relaxed, nux vomica. In 
those cases where there is pain passing from the throat to 
the ear on swallowing, bryonia. When the pharyngei mus- 
cles have a bruised feeling, cimicifuga. With a tendency to 
soreness of the tonsils, or glandular enlargement, Phyto- 
lacca. With a thick, yellowish-green secretion, pulsatilla is 
recommended, but have been disappointed in its use, unless 



142 Nose:, Throat and Ear. 

there was the typical apprehensive condition present. With 
a sensation of stuffiness at the root of the nose, with a more 
or less constant desire to blow the nose, and little or no se- 
cretion present, sticta. 

Acute: Rhinitis in Children. — This does not mate- 
rially differ from the same condition in the adult, only as 
the development of the nasal structure modifies the type. 
The inability in the very young to nurse freely, on account 
of nasal obstruction, renders the case more distressing. It 
is of the utmost importance in these cases to differentiate 
between an acute rhinitis and that of hereditary syphilis. 

Another differentiation must be made between acute 
simple rhinitis and the purulent form resulting from infec- 
tion in the parturient canal. 

Treatment. — This does not vary materially from that 
already described, excepting local cleansing is required so 
the child may breathe more freely. The nasal cavities may 
often be cleansed by the use of small rolls of blotting paper, 
or twisting absorbent cotton into a tight roll, which will re- 
move the secretion quite thoroughly. The use of the nasal 
syringe may be beneficial in these cases and is usually well 
tolerated. On account of the sensitiveness of the mucous 
surfaces, the utmost care must be exercised to avoid injury 
to the membrane. Complications are more infrequent than 
adults, but they may be the same. 



„ 



Simple; Acute; Rhinitis in Some; oe the; Constitutional, 

Diseases. 

Simple acute rhinitis is of more or less clinical impor- 
tance in a number of diseases. 

Measles. — Acute coryza is one of the prominent symp- 
toms in the initial stage. Associated with this will be in- 
jection of the conjunctiva, excessive lacrimation, photo- 
phobia, and the characteristic cough. It is claimed that at 
times, following a severe coryza, ulceration of the septum 
occurs. 



Simple Acute Rhinitis. 

DIFFERENTIAL DIAGNOSIS. 



143 



Simple Acute Rhinitis. 


Syphilitic Rhinitis. 


No specific disease of parents. 


Specific disease of one or both 
parents. 


Normal development. 


Imperfect development; 
shrivelled, senile appearance. 


Normal skin. 


Abnormal skin ; hue sallow; 
rash present. 


No systemic lesions. 


Specific lesions, condylomata, 
mucous patches, copper col- 
ored blotches, onychia, osseous 
enlargements, alopecia, or lus- 
terless brittle hair, lips ulcer- 
ated, rhagades, and infre- 
quently subcutaneous hemor- 
rhages. 


Normal. 


Liver and spleen enlarged. 


Normal. 


Child seldom smiles ; a peculiar 
plaintive feeble voice and cry. 


Normal Nutrition. 


Impaired nutrition during nasal 
attacks. 


Occasionally swelling of maxil- 
lary glands, and painful. 


Enlargement of cervical, cervico- 
maxillary, axillary and inguinal 
glands, painless. 


Fever more or less marked. 


Fever absent. 


No flattening of nose. Ulcera- 
tion absent. 


Disposition to ulceration of 
membranes and cartilages. 
Flattening of nose. 


Discharge not offensive, seldom 
streaked with blood, and 
never truly purulent. 


Discharge offensive, often 
streaked with blood and pu- 
rulent with necrotic tissue in- 
termingled. 


No formation of crusts. 


Formation of crusts, which when 
detached leave a bleeding sur- 
face. 


Fissures and ulcers of alae ab- 
sent. 


Fissures and ulcers of alae pres- 
ent. 



—Kyle. 



144 Nosk, Throat and Ear. 

Pertussis (Whooping-cough) . — Catarrhal inflammation 
of all the exposed mucous surfaces is found as an initial 
symptom of this disease, the patient presenting all the 
symptoms of having contracted a severe cold. The asso- 
ciated symptoms may make it difficult to differentiate from 
measles, until a few days have elapsed. 

Scarlet Fever. — Excepting in very mild cases, there is an 
acute catarrhal inflammation of the nasal mucous mem- 
branes, the discharge being thin, acrid, watery, or corpus- 
cular. 

Variola (Small- pox). — Decided involvement of the nasal 
mucous tissues, and pronounced coryza with associated eye 
complications, as in measles, are present. 

Typhoid Fever (Enteric Fever). — Congestion of the 
nasal tissues is frequent during the course of the disease. 
Epistaxis may be an early symptom. Unless there is ne- 
crosis of the cartilage coryza is infrequent. 

Rheumatism. — Acute Articular. — In articular rheuma- 
tism an acute rhinitis often accompanies the commencement 
of the attack, probably the result of the excess of uric acid, 
which irritates the mucous membrane which is a factor in 
the process of elimination. 

Diabetes Mellitus.— Kyle reports two cases of acute 
coryza apparently dependent upon the constitutional condi- 
tion, the severity of the attacks being apparently controlled 
by the amount of sugar in the urine. 

Epidemic Influenza (La Grippe). — A typical coryza is 
present in the thoracic form of influenza accompanied by a 
severe paroxysmal cough. 

Diphtheria. — Acute simple rhinitis is very frequent in 
this disease. It may be the initial stage of invasion of the 
disease from the pharynx, or it may result from primary 
infection of the nasal cavities. Membrane is not always 
formed in the nasal fossae, a catarrhal process being main- 
tained. 



Simple Acute Rhinitis. 145 

Erysipelas. — Acute rhinitis sometimes accompanies pri- 
mary erysipatalous infection of the nasal cavities. The in- 
flammation is severe, the tissues much swollen, and there is 
a decided tendency to extension to the nasal duct and cuta- 
neous surfaces. 

Scorbutic Rhinitis. — In infantile scurvy, there is often 
inflammation of the nasal tissues and excoriation about the 
nasal openings. 

Anemic Rhinitis. — This is a non-inflammatory state of 
the nasal tissues, in which there is engorgement of the sub- 
mucosa vessels and a clear exudate. Symptoms of an acute 
rhinitis are absent. Age is not a factor. 

Etiology. — The mucous membrane of all the functionat- 
ing organs present practically the same condition in anemic 
persons. Local irritation is absent, but with the general 
malnutrition and muscular relaxation, there is also a relaxed 
condition of the vessels of the submucosa with the conse- 
quent escape of fluid. This effusion is not from the arte- 
rioles only, but on account of the lack of tonicity of the 
vessels and walls, the circulation is impeded, and more or 
less venous stasis results. This is true of the mucous mem- 
brane of the kidneys and alimentary canal in anemia. 

Pathology. — The surface of the nasal mucous membrane 
is pale, Watery, and at the junction with the skin, a drawn 
or puckered appearance is noted. The vessels lacking the 
support of muscular tissue, readily fill with blood, but as 
the submucosa is relaxed through lack of nutrition, there is 
a decided tendency to both venous and arterial stasis. Exu- 
dation into the tissue follows, and as the nutrition is im- 
paired and there is absorption of the exudate by the epithe- 
lial cells, destruction through hydropic degeneration follows. 

Symptoms. — The general systemic line of symptoms are 
present. The nasal tissues are covered with a thin secre- 
tion, which may be irritating. It is seldom there is any tend- 
ency for the secretion to dry or form crusts on the mucous 
10 



146 Nose, Throat and Ear. 

surface, and there is no odor. The interference to normal 
respiration is usually not excessive, but in one case under 
treatment the relaxation was so marked that the inferior 
turbinal tissues moved backward and forward with each 
respiratory effort, and the noise, which might be called 
moist, could be distinctly heard in an adjoining room. The 
discharge is continuous, compelling the patient to use a 
handkerchief incessantly. The nasopharyngeal and pharyn- 
geal mucosa may also present the anemic condition, but to a 
lesser degree, as in these regions the erectile tissue is scanty 
or lacking. 

Treatment. — Local treatment alone is of little value. 
The application of an ointment of salicylic acid on a pledget 
of cotton, allowing it to remain in contact with the relaxed 
tissue an hour, if possible, will often markedly relieve the 
edematous condition. This application should not be made 
on the same side oftener than every three or four days, as 
it may produce considerable discomfort or soreness. The 
salicylic acid wash, as a cleansing agent, and also to aid in 
removing the infiltrated fluid, has given the best results in 
my experience. This should be used twice a day. If an 
atomizer is preferred, the solution should be diluted with 
water, using equal parts of each, but the solution should 
always be warmed. In constitutional treatment, the reme- 
dies given under acute rhinitis will usually be indicated, but 
the cause of the disease must be determined and treated to 
get results. If faulty heart action is partly responsible, 
Crataegus has given good results in several cases. The 
causative factor must be found and relieved. 

Scrofulous Rhinitis. 

Synonyms. — Tubercular rhinitis ; strumous rhinitis ; 
scrofulous ozena. 

Tubercular rhinitis is a term often used for this form 
of nasal disease. 



Scrofulous Rhinitis. 147 

Etiology. — This is a local manifestation of a systemic 
condition, and is found most frequently in ill-nourished 
children with an inherited predisposition to tuberculosis. 
It is usually accredited as being one of the initiai stages of 
tuberculosis, or it may be secondary to tubercular disease of 
some other portion of the body. An ulcerative process with 
a scab formation in a person afflicted with pulmonary tuber- 
culosis renders them more liable to rhinitis. 

Pathology. — Two forms of the process are found. In 
the first type there is a tubercular infiltration which pro- 
duces a well defined tumor, most frequently on the inferior 
turbinates, the nasal floor, and occasionally on the septum. 
The second type is an ulcerative process attacking the an- 
terior portion of the septum, nasal floor, or the turbinal 
tissues. 

In the first form round cell infiltration and giant cell 
formation occur. The surface of the tumor may be lobu- 
lated and papillomatous in appearance. In the second form 
the ulcer is usually shallow, edges irregular, and with no 
zone of inflammatory swelling. The secretion is white or 
yellowish in color, and tubercular bacilli are sometimes pres- 
ent. Necrosis of the turbinal bones may occur if the ulcer- 
ative process involves the turbinates. 

In these cases there is a sluggish lymphatic and circu- 
latory condition. The glands retain much of the detritus 
which should be eliminated, and frequently produces an 
ulcerative process in the adjacent structures. The ulcera- 
tive process is generally indolent in character. 

Diagnosis. — Usually there is enlargement of the cervical, 
submaxillary and sublingual glands, or there may be scars 
of a previous lymphadenitis, the characteristic anemia, 
pinched expression of the face, excoriation of the orifices of 
the nostrils, and tendency to crust formation in the nasal 
fossae. 

If any odor is present it usually is offensive. 



148 Nose, Throat and Bar. 

Pain is infrequent unless the deeper structures or ac- 
cessory sinuses are affected. When crusts form it usually 
is on account of the rapid evaporation of the watery ele- 
ments of the secretion. When perforation of the septum 
occurs it generally is multiple, thus differing from syphilitic 
perforation. 

Implication of the pharynx, soft palate, larynx, and ears 
may follow, and more or less destruction of tissue in these 
regions results. 

Prognosis. — -Always guarded. In favorable cases and 
where seen early, very good results may be obtained, but in 
the later stages it is always unfavorable. In children as 
they approach the age of puberty, the most annoying symp- 
toms subside or disappear as a rule. 

Treatment. — Constitutional measures are the most im- 
portant, although local treatment for the purpose of clean- 
liness is necessary. The following will be found especially 
useful: If — Acid salicylic (Lloyd's), 3ss; sodii boras, 
oiss ; Lloyd's hydrastis, f .gj ; aqua, q. s. f.giv. Mix. Sig. 
A teaspoonful in sufficient warm water to fill a nasal syringe 
twice. In some instances a stronger alkaline solution is 
necessary, as: If — Sodii boras, sodii bicarbonas, sodii 
chloras, aa. 3ij ; aqua, gxvj. This is to be used full strength, 
but must be warmed. 

Constitutional Treatment. — When there is a tough, 
stringy, tenacious secretion, or with a crust formation, which 
when dislodged is streaked with blood, potassium bichro- 
mate. When the secretion is thick and yellow, but not puru- 
lent, arsenic iodide. If a passive epistaxis occurs, carbo- 
veg. or dist. hamamelis. With a distinctly purulent secre- 
tion, lime in some form. A moderately profuse and moder- 
ately thick secretion, hydrastis. With a tendency to ulcera- 
tion of the bony or cartilaginous structures, the patient hav- 
ing light hair, eyes and complexion, gold and sodium 
chloride. Phytolacca is nearly always required in these 



Epidemic Influenza. 149 

cases on account of glandular enlargement, acd lime also 
is indicated even without ulcerative processes. 

Hygienic measures are of the utmost importance. 
Plenty of outdoor exercise, not carried to the point of 
fatigue, however. Nutritious food, properly ventilated 
sleeping rooms and freedom from both mechanical and 
chemical irritants. The excretory functions should be kept 
in as nearly a normal condition as possible. 

Caseous Rhinitis. 

Synonyms. — Coryza caseosa ; cholesteatomatous rhinitis ; 
rhinitis caseosa. 

This disease is infrequently seen, and does not seem to 
implicate the mucosa, but rather is the result of some asso- 
ciated condition. There is an accumulation of a cheesy, 
gelatinous substance in the nasal fossae, which may be so 
abundant as to produce displacement of the structures and 
facial deformity. The odor accompanying this disease is 
very fetid. The material is composed of cholesterine crys- 
tals, granular leukocytes, fatty cells and stearin. A tuber- 
culous, or syphilitic, taint appears to favor the disease. In 
the report of one case, the cause was ascribed to degenera- 
tion of a myxomatous growth. 

Treatment. — Removal of the material by curettement, 
cleansing with an alkaline solution, followed by the salicylic 
acid solution. 

Epidemic Influenza. 

Synonym. — La Grippe. 

Coryza is usually very severe, and nearly always a pain- 
ful, paroxysmal cough accompanies it. The systemic symp- 
toms usually appear so early that a mistake in diagnosis is 
practically inexcusable. The effects of this disease on the 
mucous membrane of the upper respiratory tract and acces- 
sory sinuses, as well as the sequelae, are important. 



150 Nose, Throat and Ear. 

Pfeiffer's bacillus is now supposed to be the causative 
factor of this disease, but its method of attacking and pene- 
trating tissues, is certainly erratic. Acute otitis media, 
which rapidly becomes a suppurative process is frequent, as 
well as acute mastoid disease. Either or both of these may 
be associated with or follow la grippe. 

The frontal sinuses are usually affected in the early 
stages of the disease. The ethmoid cells are affected either 
early or during the most severe stage, and often becomes a 
chronic suppurative ethmoiditis, in which it differs from an 
ethmoiditis resulting from ordinary coryza, or that result- 
ing from the infectious fevers. The antra of Highmore are 
the most frequently affected, suppuration rapidly occurring. 

Tonsillar and peritonsillar inflammation is frequent, and 
usually ends in suppuration. 

The effects of epidemic influenza on the mucous mem- 
brane are variable, and seemingly not in proportion to the 
severity of the attack. A mild attack may cause a per- 
sistent irritated and thickened condition. The pain and dis- 
comfort during such an attack may be much more severe 
than the macroscopic appearances would indicate. Occa- 
sionally blood clots will form on the membrane of the upper 
respiratory tract, without a true hemorrhage, and the mem- 
brane will be sensitive, dry and painful, and with very little 
swelling. The removal of the clots will not be followed by 
bleeding, but in two or three hours there will be new clots. 
The usual location is in the pharynx and nasopharynx, al- 
though it may occur in the nares. The expectoration of 
blood-stained mucus will have, in conjunction with the 
disease depression, a decidedly depressing effect. 

After the subsidence of the disease, there is often both 
a subjective and objective thickening of the mucous mem- 
brane. The tissue presents a tough and infiltrated appear- 
ance, and the entire mucous structure is usuallv affected. 



Croupous or Pseudomembranous Rhinitis. 151 

Membranous Rhinitis. 

This classification includes: (a) Croupous or pseudo- 
membranous rhinitis; (b) fibrinoplastic rhinitis; (c) diph- 
theritic rhinitis — usually conceded to be due to the Klebs- 
Loffler bacillus. 

Croupous or Pseudomembranous Rhinitis. 

Synonyms. — Membranous rhinitis ; primary pseudomem- 
branous rhinitis. 

An acute inflammation of the mucous membranes. Age 
offers no immunity, although it is neither so severe nor of 
as long duration in the adult as in children. The false mem- 
brane which forms upon the epithelial surface is albuminous 
in character, does not show a tendency to organize, nor are 
the deeper structures involved. 

Etiology. — Croupous rhinitis in many cases is supposed 
to be due to irritation resulting from micro-organisms on 
the mucous surfaces, when there is diminished cell resist- 
ance; or as a result of subnormal resistance through sys- 
temic conditions. There is no one specific bacterial form 
which causes the disease. The streptococcus pyogenes is 
supposed to be the most frequent factor, but there may be 
associated with them other forms of staphylococci, and the 
attenuated form of diphtheria bacillus (Von Hoffman's 
bacillus). Croupous rhinitis has been observed following 
the use of the galvanocautery or other operations in the 
nasal cavities. Cases have also been reported as sequelae 
of measles, tonsillitis and also in hereditary syphilis. 

Poor hygienic conditions, or any cause which dimin- 
ishes the resisting power of the mucous surfaces may be a 
factor. 

Pathology. — Primarily the pathology is that of acute 
catarrhal rhinitis. Swollen, turgid, and congested mucosa, 
followed by an excessive exudate of serum and cellular ele- 



152 Nose, Throat and Ear. 

ments upon the membrane. The secretion is mildly puru- 
lent, and excoriation of the nasal openings and upper lip 
occurs. The discharge is seldom fetid. When fully devel- 
oped, the membrane will usually be found on the surface of 
the lower and middle turbinates and the anterior part of the 
septum. It may be slight, or involve the entire nasal cavity. 
Recurrence is usual upon removal of the membrane. In 
adults the membrane is thin and gelatinous, but tenacious 
•and of a pearly tint. In children it is liable to be thicker and 
may be friable. The membrane is composed of a network 
of fibrin with leukocytes, red blood cells, desquamated epi- 
thelium, and bacteria. 

Symptoms. — The initial stage is the same as in acute 
rhinitis. Mouth breathing soon follows as a result of oc- 
clusion of the nasal fossae through swelling of the tissues. 
The dry stage is short, there soon being an excessive secre- 
tion, at first clear, but soon becoming opaque and thicker. 
Although the fever subsides, malaise continues. Frontal 
headache, more or less loss of smell, and neuralgia of the 
nasal nerve may occur. When the secretion thickens, shreds 
or small pieces of false membrane are formed, which gen-* 
erally is the first distinctive feature of the disease. Inspec- 
tion of the nasal cavities will reveal the membrane, unless 
occlusion has resulted from excessive swelling of the tissues. 
In} adults this condition lasts from eight to fourteen days, 
and in children from ten days to five weeks. 

Diagnosis.— The shreds of membrane in the discharge, 
and the presence of membrane in the nasal cavities differ- 
entiate it from acute rhinitis. The table will give the differ- 
ential diagnosis between croupous and diphtheritic rhinitis. 

Prognosis. — Favorable, but the possibility of subsequent 
attacks must be remembered. 

Treatment. — Locally. — The use of the alkaline solution, 
followed with the salicylic acid solution. If any of the 
membrane remains, it may be removed by the use of cotton 



Croupous or Pseudomembranous Rhinitis. 153 



with the cotton carrier, but care must be used to avoid in- 
juring the sensitive mucous membrane. The insufflation 
of the following powder will be found beneficial. 1J — Acid 
salicylic, gr. xx ; Acid Boric ovj ; used with a Devilbiss pow- 
der blower. 

DIFFERENTIAL DIAGNOSIS. 



Croupous Rhinitis. 



Diphtheritic Rhinitis. 



Systemic symptoms not severe. 

Sporadic, 

Primary. Membrane seldom ex- 
tends beyond the nasal cavi- 
ties. 



Albuminuria absent. 

Lymphatic glands not enlarged. 

Membrane brighter colored and 
pearly. 

Superficial. 

Easily removed. 

On removal no bleeding surface, 
possibly slight capillary ooz- 
ing. 

Neither ulcer nor scar follows 
removal. 

Discharge slightly if at all fetid. 

May be found at any age. 

Paralysis of velum absent. 



Systemic symptoms usually se- 
vere. 

Epidemic usually. 

Generally secondary, it may be 
by auto-infection or extension, 
faucial or pharyngeal false 
membrane preceding or ac- 
companying the nasal mem- 
brane. 

Albuminuria present. 

Cervical lymphatics enlarged. 

Membrane dirty or grayish 
white ; rough. 

Deeper layer of mucous mem- 
brane. 

Difficult to remove. 

On removal bleeding more or 
less profuse. 

Ulceration and subsequent scar 
may follow removal. 

Discharge fetid. 

Usually in children. 

Paralysis of velum may be pres- 
ent. 



Internal. — During the fever, aconite. Potassium bi- 
chromate will aid in preventing the formation of the mem- 
brane. If the disease is confined exclusively to the nasal 
cavities, potassium iodide or jaborandi. The bowels should 



154 Nose, Throat and Ear. 

be moved with a saline cathartic, and for children the solu- 
tion citrate of magnesia is usually preferable. 

Fibrinoplastic Rhinitis. 

The exudate is similar to that of the croupous form, but 
is more fibrinous, with a tendency to organization. The 
general health is not usually affected in this disease, al- 
though there is often a previous lowered vitality, the result 
of poor hygienic conditions. The disease is most frequent 
m youth. 

Fibrinoplastic rhinitis commences similarly to any 
catarrhal inflammation, and is quickly followed by a coagu- 
lable, albuminoid fibrinous secretion. The pharynx and 
tonsils may be implicated through extension. The mem- 
brane may be fairly adherent to the mucous membrane, and 
if forcibly detached, leaves a bleeding surface. There have 
been no specific germs discovered in the exudate, except 
staphylococci. The disease is sporadic, neither infection 
nor contagion being found. The disease assumes a chronic 
type. 

Treatment. — The alkaline wash followed by the salicylic 
acid solution. The advisability of forcibly removing the 
membrane will depend upon the condition of the nasal pas- 
sages. If occluded, the membrane may be removed with 
forceps, but usually it is preferable not to do so. The in- 
sufflation of salicylic acid and boric acid often aids in caus- 
ing detachment, and preventing the membrane reforming. 
The internal administration of potassium bichromate, Phyto- 
lacca, or jaborandi will usually be indicated. 

Diphtheritic Rhinitis. 

Synonym. — Nasal diphtheria. 

This is an acute inflammation of the nasal mucous mem- 
brane, and may be primary, but usually is secondary to 
pharyngeal diphtheria. 



Occupation Rhinitis. 155 

Occupation Rhinitis. 

Synonym. — Traumatic rhinitis. 

Etiology. — The acute inflammation of this form, may 
result from irritating vapors, as ammonia, bromine, iodine, 
chlorine, etc., or the inhalation of floating irritating mate- 
rial in the air ; as found in flour mills, or among coal miners, 
tvood carvers, weavers, hat makers, etc. Steam "and smoke 
also come under the list of causes, but the nasal membranes 
are not affected as much as the pharyngeal. Foreign bodies 
or direct injury are often factors. The fumes of many vola- 
tile drugs will not only cause the condition, but will also 
prevent any especial relief, until the exciting cause is re- 
moved. 

Pathology. — The morbid changes do not vary from those 
of simple acute rhinitis, unless the result of the irritating 
fumes of potassium bichromate, arsenious acid, or mercury, 
the effect being only local. Subsequent to the acute in- 
flammation, local areas of degeneration may be found, which 
implicate the submucosa, forming ulcers, at first small and 
round, gradually becoming larger and oval. This generally 
occurs on the cartilaginous portion of the septum and some- 
times causes perforation. 

Symptoms. — The general symptoms are tickling sensa- 
tions in the nose, followed by paroxysms of sneezing, ac- 
companied or followed by a profuse secretion. This secre- 
tion is watery in character at first, but later assumes a 
greenish tinge, is thicker and more tenacious. When super- 
ficial necrosis begins, the secretion forms in crusts, and as 
the process goes on to ulceration, hemorrhage occurs. There 
is seldom any fetor. The upper and posterior portion of the 
cartilaginous septum is most frequently affected by the ulcer- 
ative process, although the turbinates may be ulcerated. 
The lower anterior portion of the cartilage is not affected, 
and falling in of the nose does not occur. 



156 Nose, Throat and Bar. 

Prognosis. — Usually good if the exciting cause is re- 
moved. It is supposed that those who recover from this 
form of rhinitis are less likely to have catarrhal inflamma- 
tion of the nasal tissues. 

Treatment. — Removal of the cause is essential. If the 
patient's vocation is such that avoidance of the irritating 
material is impossible, the nasal tissues should be protected 
from the irritant, preferably by the use of a mask or inhaler, 
but the use of moistened plugs of cotton or wool may be 
used, changing them frequently, especially when exposed to 
acrid or acid fumes. 

Locally the alkaline wash or salicylic acid wash. In- 
ternally when there is a tendency to ulceration, or if ulcera- 
tion has commenced, the administration of potassium bi- 
chromate. Local cleanliness, however, is of the utmost im- 
portance. 

Acute Edematous Rhinitis. 

This is not to be mistaken for rhinitis edematosa or 
cyanotic rhinitis. The acute phenomena are the same as in 
edema of other regions. It is especially liable to occur in 
this region as there is no muscular support to the mucous 
membrane. 

This form of rhinitis may result from any sudden change 
in the vascular tissue, which, becoming overdistended, a 
watery infiltration occurs of the connective tissue spaces 
of the submucosa connective tissue cells, and possibly of the 
surface epithelial cells. If this distention continues until 
nutrition is impaired, hydropic degeneration will result. In- 
flammatory processes follow instead of precede in this type. 
It may result from the inhalation of steam, very irritating 
vapors, injuries of the membrane, or of the bony cartilag- 
inous or connective tissue of the nose. 

Treatment. — If there is complete occlusion of the nasal 
cavities, it will usually be necessary to puncture the de- 
pendent portions. The use of pledgets of cotton saturated 



Phlegmonous Rhinitis. 157 

with glycerine or covered with the salicylic acid ointment 
will usually afford prompt relief. Internally, apis or apocy- 
num. The acute symptoms usually subside in one or two- 
days without any treatment. 

Phlegmonous Rhinitis. 

This is either an acute abscess of the septum, or of the 
submucosa. The position and severity of the lesion is al- 
most the only difference from a nasal furuncle. 

Diagnosis. — A distinct circumscribed swelling on one or 
both sides of the septum. The appearance and course are 
similar to an acute abscess elsewhere. The disease differs 
from ordinary furunculosis in not usually appearing in 
crops. If possible to abort the suppurative process, it 
should be done, but on account of the location this is not 
often accomplished. An alcoholic saturated solution of 
boric acid or tr. iodine may be applied. Internally the 
administration of lime. After suppuration has occurred, a 
free incision should be made, and the cavity frequently 
cleansed with an alkaline wash. Empyema of the antrum 
of Highmore, or an alveolar abscess, the result of carious 
teeth may be present at the same time. 



CHAPTER VII. 

DISEASES OF THE ANTERIOR 
NASAL CAVITIES. 



CHRONIC INFLAMMATORY DISEASES. 

Chronic Rhinitis, (i) Simple Chronic Rhinitis; (2) In- 
tumescent Rhinitis; (3) Hyperplastic Rhinitis; (4) Ozena 
as a Symptom; (5) Atrophic Rhinitis; (6) Purulent Rhini- 
tis; (7) Nasal Hydrorrhea; (8) Edematous Rhinitis (Cya- 
notic) ; (9) Specific Inflammations (Granulomata) ; (a) 
Syphilis. (1) Acquired. (2) Congenital, (b) Tuberculosis; 
(c) Glanders; (d) Leprosy; (e) Actinomycosis; (f) Rhino- 
scleroma. 

Simple Chronic Rhinitis. 

Synonyms. — Catarrhus longus ; simple chronic nasal 
catarrh ; chronic rhinitis ; chronic nasal catarrh ; chronic 
coryza ; chronic blennorrhea ; chronic rhinorrhea ; rhinitis 
chronica ; rhinitis simplex ; fluxus nasalis. 

This is a chronic inflammatory action of the nasal 
mucous membrane, resulting from prolonged irritation or 
repeated attacks of the acute type, especially when neg- 
lected. It is intermediate between acute and commencing 
atrophic rhinitis. 

Etiology. — Chronic rhinitis may be the result of re- 
peated acute attacks, the continuation of a neglected severe 
attack, and occasionally no cause can be assigned. Debili- 
tated conditions of the muscular or nervous systems are 
conducive to the development of this disease. Predisposing 
causes are the same as those producing acute rhinitis. The 

158 



Simple Chronic Rhinitis. 159 

disease is especially liable to follow the simple acute rhinitis 
which occurs in infectious diseases, or the acute rhinitis of 
the new-born. The disease is often seen between the ages 
of sixteen and thirty-five. 

Pathology. — Relaxation of the membrane and erectile 
tissue. The characteristic appearance of atony of the vas- 
cular system will be present. The tissues being flabby and 
readily distended with blood. The contractile power of the 
vessels is more or less diminished. There is venous engorge- 
ment of the erectile tissue. The walls of the blood vessels 
become more permeable to the inclosed fluid and there is 
escape, especially of the white corpuscles of the blood, into 
the surrounding tissue. These elements proliferate and in 
connection with the proliferation of the fixed connective 
cells, new tissue of inflammatory origin is formed. The con- 
tinuation of the chronic inflammatory stage after the newly 
formed tissue is organized, marks the intermediate stage, 
which eventually leads to atrophic rhinitis. This interme- 
diate stage is frequently mistaken for hypertrophic rhinitis. 
There is more or less exudation on the surface, intermingled 
with migrated cells and degenerated epithelium. Glandular 
atrophy results from the pressure, both of vascular disten- 
tion and increase of connective tissue. 

Symptoms. — Usually the first symptoms are irritation of 
the nose, or increased nasal or postnasal discharge. Slight 
exposure will increase the secretion, and there will be a 
slight sense of discomfort in the nose. During the early 
stages the secretion is usually thin and watery ; later it gen- 
erally becomes thicker, more tenacious, mucopurulent or 
purulent. Occasionally there may form dry, greenish crusts, 
or thin strings of secretion extending across the nasal pas- 
sages. If the crusts remain for any length of time, they may 
become infected, and emit an annoying odor. If the patient 
continually "picks the nose" to remove the crusts, the irri- 
tation produced may result in ulceration of the vestibular 



160 Nose, Throat and Ear. 

and septal tissue with perforation. The discharge in the de- 
bilitated may be profuse, non-irritating, clear, and watery. 
An intermittent partial or complete occlusion of the nose 
may occur, but a "stuffy" sensation is nearly always pres- 
ent, with a dull heavy pain over the bridge or at the root of 
the nose ; dull frontal headache, the result of closure of the 
infundibuli, and occasionally hebetude and indisposition to 
work will be present. The neuroses which often accompany 
this disease are itching or tickling in the nose ; sneezing ; 
spasmodic cough, usually dry ; vomiting, or asthma. There 
is a slight "nasal twang" to the voice. 

In the later stages the sense of smell is usually impaired. 
Disturbances of the digestive apparatus, probably due to 
swallowing the secretion, will often produce a general de- 
bility of the system. Attacks of acute rhinitis are frequent 
on slight exposure, especially in damp weather. Redness 
of the tip and alse of the nose is often present in cases of 
long standing, and may be accompanied with more or less 
swelling of the tissues. Inspection of the nasal cavities will 
reveal a diffuse, more or less swollen membrane, especially 
on the middle and inferior turbinates and the septum, red, 
soft and cushion like, with some portions covered with se- 
cretion. Hyperesthetic areas are usually found. 

I Pressure with a probe will cause the tissue to pit easily, 
the indentation disappearing slowly. The application of a 
solution of cocaine, or preparations of the suprarenal gland 
will cause a contraction of the swollen tissues. These 
methods differentiate a chronic rhinitis from a hypertrophic, 
as in the latter the tissues do not pit readily, and the inden- 
tation quickly disappears, and with the constringing agents 
there is only a partial subsidence of the swollen tissue. In 
persons much debilitated, or the aged, the membranes may 
be pale, and bathed with a watery secretion. The secretion 
varies, but may be thin, thick, scanty, copious, bland, ex- 
coriating, white, discolored, or bloody. The disease is most 






Simple Chronic Rhinitis. 161 

annoying in spring, autumn, and winter, but usually causes 
little annoyance in the summer, unless the vocation requires 
the patient to be exposed to irritating dust or vapors. 

Diagnosis. — The history of the case, careful inspec- 
tion, and palpation of the tissues with a probe, or the use 
of contractile agents. 

Prognosis. — The occupation of the patient and hygienic 
surroundings will have much to do with the prognosis. 

Complications. — There may be more or less loss of 
the sense of smell, and necessarily a corresponding loss of 
the sense of taste. Implication of the Eustachian tubes will 
cause aural complications. The accessory sinuses and lacri- 
mal drainage system may be affected. Granulation tissue 
or polypi may also be unpleasant complications, and diges- 
tive disturbances are frequent. 

Treatment. — Constitutional treatment is of the utmost 
importance in this as in the majority of catarrhal affections. 
In chronic rhinitis the cause of the disease and its elimina- 
tion is necessary. Such measures as will relieve the annoy- 
ing symptoms resulting from the changes in the mucous 
structures, are also necessary, as these changes otherwise 
remain after the removal of the exciting cause. Hygienic 
measures are a necessity, as 'the general health must be 
maintained. 

Local measures will consist of cleansing the mucous sur- 
faces, and the salicylic acid solution will be the most gen- 
erally useful. For relieving the swollen condition of the 
mucous tissues, the introduction of a pledget of cotton cov- 
ered with the salicylic acid ointment, will quickly relieve, 
giving more respiratory space. The amount of secretion is 
usually much increased on removal of the cotton, as exosmo- 
sis results from the application, decreasing the amount of 
infiltration. The mechanical pressure of the cotton and 
stimulating action of the acid, soon produces enough re- 
traction to give relief. The application should not be made 
n 



1 62 Nose, Throat and Ear. 

to the same side oftener than twice a week, and should be 
persisted in for from three to six weeks. 

Constitutional. — Where there is anemia and malnutri- 
tion, a relaxed condition of the mucous membranes and the 
secretion a thin mucus, iodide of iron. If the secretion is 
purulent, lime in some form. A moderately profuse dis- 
charge from both the anterior and posterior nares, Hydras- 
tis. In nervous. women, with a relaxed condition of the 
tissues, but ho apprehensiveness, ignatia. With relaxed tis- 
sues and gastric complications, atonic in character, mix 
vomica. Hydrastis is also usually indicated in this con- 
dition. When there is a persistent, stuffed sensation near 
the root of the nose, with a desire to blow the nose and little 
or no secretion obtained, sticta. When the secretion is 
tough, tenacious, and stringy, potassium bichromate. With 
lymphatic glands or glandular tissue swollen, phytolacca. 
A thin, watery, nonexcoriating secretion, hamamelis. Thin, 
watery, excoriating discharge, liquor potassii arsenitis. In 
strumous cases, arsenic iodide. 

Operative.— -If polypi are present, their removal is im- 
perative, as no treatment will be beneficial as long as these 
growths remain as irritants. When possible to do so they 
should be removed with the cold wire snare. When through 
deformity of the structures, this is impossible, the use of 
scissors should take precedence, but some cases will present 
in which the forceps will have to be employed. 

In many cases there will be found a hanging turbinate, 
usually the middle. This condition causes an irritation and 
thickening of the mucous tissue, and if the turbinate is large 
and spongy it may be necessary to operate, removing a por- 
tion of the bone. Generally the thickening is confined to 
the mucous tissues, and the use of the tampons of cotton 
with the salicylic acid ointment, or graduated pressure with 
malleable nasal tubes should be tried before radical meas- 
ures are resorted to. In the use of the tubes, they should 



Intumescent Rhinitis. 163 

be fitted to the cavity and gradually enlarged. The time 
they are worn at first is only one or two hours, increasing 
the time as the irritability of the tissues diminishes. An- 
other method is to scrape the bony structure with a sharp 
pointed probe. Cocainizing the tissue and making a punc- 
ture, pass the probe to the periosteum, and gently scrape the 
tissue. Inflammatory action will result and the contraction 
following will relieve the turgescence. The use of a Graefe 
cataract knife introduced in a similar manner to the probe, 
will also be followed by reduction of the turgescence with- 
out destruction of the epithelial surface. 

The indiscriminate removal of turbinal tissue is to be 
deplored, and the operation should never be performed ex- 
cepting as a last resort. When it is necessary to remove a 
portion of the bone, the mucous tissue should be dissected 
from the bone and the edge only of the bone removed, as a 
rule. In many of* these cases, much benefit can be obtained 
by electrolysis or kataphoresis, especially when the result 
of local lesions. The employment of the actual or galvano 
cautery in these cases is seldom beneficial, as the difficulty of 
controlling the destruction of tissue is extremely difficult. 

Intumescent Rhinitis. 

This is really not a distinct form, but a modification of 
chronic rhinitis. One or both nasal passages may show a 
sudden turgescence with a permanent boggy state of the 
mucous membrane. Changes in the structure of the sub- 
mucosa are not marked, as the membrane will often become 
almost normal. In recurrence there is an excessive secre- 
tion, sometimes clear and watery, or tenacious and muco- 
purulent. Accompanying or preceding the exacerbation 
there may be excessive itching, due to the irritation caused 
by the vascular change. Frequently there is engorgement 
of the cutaneous vessels, the skin being reddened and some- 
what sensitive. 



1 64 Nose, Throat and Ear. 

Symptoms. — A characteristic of this lesion is the rapid- 
ity of the swelling of the turbinal and septal mucous mem- 
brane. The exudate causes the swelling, and differentiates 
it from cyanotic rhinitis which is produced by engorgement 
of the vessels. Both cavities may be affected at the same 
time, or they may be alternately swollen. In lying on the 
side, the lower nasal cavity will usually be occluded. The 
liability to colds, especially in the fall, winter, and spring, 
is much increased in persons having this disease. Hoarse- 
ness on arising is often complained of, and ther.e is more or 
less difficulty in expectorating the mucus which clings to the 
tissues, especially of the soft palate. Occasionally the ef- 
forts to dislodge the material will cause vomiting. A hack- 
ing cough may annoy the patient, as well as an irritating 
hoarseness on prolonged use of the voice for speaking or 
singing. Dull frontal headache ; tired sensation in the eyes ; 
dryness and tickling in the throat ; coated tongue and gastric 
disturbances and offensive breath are symptoms sometimes 
found. 

Prognosis. — Usually favorable. 

Treatment. — Essentially the same as for simple chronic 
rhinitis. The itching sensation can usually be quickly re- 
lieved by stearate of zinc with europhen. 



Hyperplastic Rhinitis. 

Synonyms. — Obstructive rhinitis ; Hypertrophic nasal 
catarrh ; Hypertrophic ozena ; Hypertrophy of the turbi- 
nated bones ; Chronic hypertrophic rhinitis ; Hypertrophic 
rhinitis. 

This is a chronic disease affecting the entire structure of 
the mucous tissue. 

Etiology. — The etiology and pathology of so-called hy- 
pertrophic rhinitis is a vexed question, as there is consid- 
erable diversity of opinion regarding the disease, and also 
a great deal of confusion as to the diagnosis. It is fre- 



Hyperplastic Rhinitis. 165 

quently difficult to distinguish between a chronic rhinitis, 
intumescent rhinitis, and the hypertrophic form so-called, 
as during some of the stages of each the symptoms are 
essentially the same, but the final stage is very different. In 
the hyperplastic, or hypertrophic form, the increase of con- 
nective tissue elements of the submucosa is similar to that of 
a benign tumor, and remains practically the same, not con- 
tracting as does the tissue resulting from inflammatory proc- 
esses. The disease may result from repeated or continued 
attacks of chronic rhinitis. Climate seems to have but little 
to do with the condition. 

Pathology. — There is increased connective tissue forma- 
tion, as a result of constant irritation causing hyperemia, 
but not producing a true congestion. Xew gland tissue may 
also be formed as a result of this increased tissue, but there 
is not a normal function of the new gland tissue. Increased 
fibrous structure is found in the submucosa, the vessels be- 
ing abnormally separated by the thickening of the connective 
tissue support. There is an increase in the capillary sup- 
ply, but the basement membrane is but little if any changed. 
The epithelial portion is thickened and there is an increase 
of cell layers. The external layer may be ciliated and the 
inner layer of the columnar type. Folds and furrows are 
present in the epithelial structure. 

Symptoms. — There are no specially characteristic symp- 
toms differentiating this from several other forms of rhini- 
tis. One or both sides may be involved, and the morbid 
process may be located in either the anterior or posterior 
portion of the turbinal tissue, or cover the entire surface. 
The progress of the disease is essentially chronic. The color 
of the membrane varies according to the stage and amount 
of thickening. The character and quantity of the discharge 
varies. There may be an increase in the turbinated bony 
structure. Often there will be found deflection of the sep- 
tum, exostosis or enchondrosis. Not infrequently the diag- 



166 



Nose, Throat and Ear. 



nosis of a fibrous polypus is made on account of the ap- 
pearance of the thickened mucous tissues. Nasal respira- 
tion is impaired, and slight irritation will produce a marked 
engorgement of the tissues. Any position which facilitates 
gravitation, will increase the distention of tissue. The con- 
stant impairment of nasal respiration, especially during 
sleeping hours, promotes the habit of mouth breathing. 
The secretion is tough, tenacious, and thick, even when 




FiG. 60. Hyperplastic rhinitis, all the tissues of the middle and 
inferior turbinates affected. The nasopharynx showing fimbriated 
adenoid growths. 



scanty, and is difficult of removal. The sense of smell is 
impaired or lost entirely. The tissues of the anterior region 
of the nose may be nearly normal in color or reddened. 
The anterior portions of the inferior and middle turbinates 
may be much swollen, smooth, or lobulated, and that of the 
inferior may project sufficiently to touch the septum. The 
septal tissues present irregular areas of swollen tissue, espe- 
cially the lower portion. In many cases the changes in the 
anterior portion of the nasal cavities are not marked, but 



Hyperplastic Rhinitis. 167 

the posterior portion, especially of the inferior turbinate 
will be much affected. The rhinoscopic mirror will reveal 
a rounded whitish mass, which may be lobulated. The mid- 
dle turbinate may present the same appearance to a lesser 
degree. These masses may partially or completely fill the 
choanae, and sometimes may project into the vault of the 
pharynx, encroaching on the orifices of the Eustachian 
tubes. The so-called mulberry form is regarded by some 
as an early stage of the disease. The color is dark red or 
purplish, and the mass may bleed on slight irritation. The 
posterior portion of the septum may also present either of 
these conditions. The middle portion of the turbinates may 
present the same appearance as either the anterior or pos- 
terior parts. Frequently pedunculated masses, and papillo- 
matous like growths may be found projecting from the tur- 
binates. Longitudinal grooves may be found on the sep- 
tum, the result of pressure from the impinging turbinates. 
The superior turbinates and roofs of the fossae are seldom 
implicated in the morbid process. 

Eye complications are frequently present when the supe- 
rior portion of the nasal cavities are affected. 

The quality of the voice is changed, there being a nasal 
twang to the voice, as a result of interference with nasal 
resonance. Conjunctival irritation and epiphora ?.s a result 
of occlusion of the nasal duct is frequently present when 
the middle turbinate is affected. Impaired hearing will 
result when the posterior portions of the middle and in- 
ferior turbinates are involved, through interference with 
the Eustachian orifices. Frontal headache of a dull, inter- 
mittent character is often present. Retention of secretion 
in the nasal cavities may result from both the irregular sur- 
faces and change in the consistency of the secretion. The 
secretion may become offensive. Cough may result from 
the secretion passing into the nasopharynx. If mucoid de- 
generation takes place, the tissues appear whitish or gray- 



1 68 Nose, Throat and Kar. 

ish. A sensation of fullness and pressure over the bridge of 
the nose is not uncommon. Nasal polypi are not infrequent 
complications. 

Diagnosis. — The differential diagnosis between hyper- 
plastic rhinitis and chronic, intumescent or cyanotic, as 
well as the engorgement of mucous tissue found in plethoric 
persons, is important. There should be preservation of all 
the mucous membrane possible in the hyperplastic form, as 
there can be no return to normal function of the membrane, 
while in the other types there may be. The application of 
cocaine* does not produce much shrinking of the tissues, and 
the use of a probe will not produce pitting unless consid- 
erable pressure is made, and the depression disappears 
slowly. 

Prognosis. — Usually favorable as regards relief. 

Complications. — Naso-pharyngitis, pharyngitis, laryn- 
gitis, tracheitis or bronchitis, are pretty certain to follow, 
and in persons predisposed to pulmonary phthisis, it may 
be the starting point of this disease. Dyspepsia is also fre- 
quently a complication. As reflex conditions, epilepsy, 
asthma, chorea, spasms of the glottis, optic neuritis, sco- 
toma, hyperemia of the fundus, orbital neuralgia, and even 
glaucoma may occur. Ear complications are frequent. 
Tolypi and adenoid growths are often present. 
J Treatment. — Local treatment should be carefully em- 
ployed for the purpose of cleanliness, but if carelessly used 
it will do harm by needlessly irritating the tissues. Opera- 
tive measures are necessary in all but the mildest cases. The 
removal of excess of tissue is imperative. The use of caus- 
tic preparations is not generally advisable as the destruction 
of tissue is not always readily controlled. The damage 
which may result from the use of the actual cautery, except 
in experienced hands, must be remembered. By the use of 
a proper knife, a wedge-shaped incision may be made and 
the redundant tissue removed with a scissors or snare. 



Ozena. 169 

When the turbinated bone is thickened or hanging, the 
mucous membrane should be dissected from the bony struc- 
ture and the edge of the bone removed by the saw or for- 
ceps. The portion bf tissue removed should be that which is 
most prominent or is producing the most irritation or ob- 
struction. For cleansing the nasal cavity after an operation 
either the saline wash or salicylic acid wash should be used 
with the nasal syringe. If the tissue is sessile, the use of 
the cold wire snare is preferable. Plenty of time should be 
taken in using the snare, as the operation will be less pain- 
ful and there will also be less hemorrhage. In some .cases 
it will be better to cauterize the traumatic surface with 
chromic acid fused on an applicator or probe. The use of 
the galvano-cautery is attended with too much danger ex- 
cepting in the hands of an expert. Electrolysis has given 
good results in many cases, using the bipolar method, and 
using a double needle. The current should be gradually 
increased from five to ten milliamperes, and as gradually 
diminished, two to five minutes time will be sufficient. 

Ozena. 

The term ozena has, like malaria, been used to cover a 
multitude of sins, as it has been applied indifferently to 
various diseases of the nose. The true significance of the 
term is a ''stench," and is simply a symptom, the same as a 
cough, and should not be classed as a distinct disease. 
Ozena may be present in atrophic rhinitis, syphilis, suppura- 
tive diseases of the accessory sinuses, coryza caseosa, 
glanders, malformation of the nasal structures, neoplasms, 
or a foreign body in the nasal space. The odor may be 
slight or extremely offensive. The patient may or may not 
be conscious of it. It may be intermittent or constant and 
is not always modified by the use of disinfectant methods. 
Various theories regarding the cause of the odor have been 
advanced, but the most rational appears to be that it is the 



170 Nose, Throat and Ear. 

lesult of putrefaction changes in the secretion and tissues 
involved. Ozena is in no sense of the word a disease, but 
a symptom. 

Atrophic Rhinitis. 

Synonyms. — Atrophic catarrh ; Atrophic nasal catarrh ; 
Chronic atrophic rhinitis ; Chronic fetid rhinitis ; Cirrhotic 
rhinitis ; Dry catarrh ; Dry nasal catarrh ; Dysodia ; Fetid 
atrophic rhinitis ; Fetid catarrh ; Fetid Coryza ; Fetid rhi- 
nitis; Idiopathic or constitutional ozena; Ozena; Rhinitis 
atrophica ; Rhinitis atrophica simplex ; Rhinitis fcetida atro- 
phica ; Rhinitis sicca ; Sclerotic rhinitis ; Simple ozena ; 
Atrophic endorhinitis. 

Atrophic rhinitis may be generally classified as primary 
or secondary, although it is neither a true distinct process 
nor an inflammatory condition, but follows some previous 
affection. 

Primary, when a direct lesion as simple atrophy or a tro- 
phic process. 

Secondary, when the result of a pre-existing local lesion 
which causes the atrophy, or when the result of a morbid 
process in some other region. 

The causes of atrophy may be subdivided as follows : 

Atrophy, the result of an inflammatory process which is 
followed by contraction, thus lessening the blood supply. 
This may produce atrophy and by pressure will probably 
diminish the function of the glandular elements. 

Interference of the general circulation may cause over- 
distention of the vessels of the submucosa, thus producing 
pressure which will be followed by connective tissue and 
glandular atrophy. 

The primary cause of the atrophy will determine the 
treatment of these cases, if seen before the final atrophic 
changes have taken place. 

General Considerations. — Atrophy and degeneration are 



Atrophy from a Pre-existing Local Lesion. 171 

separate changes. In simple atrophy the nutrition is les- 
sened and function impaired, although there may be -no wast- 
ing of the tissue, but rather an increase through fluid disten- 
tion, although there are lessened structural elements. The 
size and probably the number of cellular elements are dimin- 
ished, but the individual cell is present, which may, through 
proper treatment be restored to approximately its normal 
state. 

In degeneration there is complete loss of function, and 
the cell undergoes a complete change so that a return to 
normal action is impossible. If the case is seen during the 
atrophic stage proper and the exciting cause can be re- 
moved, a return to normal conditions may be obtained, but 
after degenerative changes have occurred, this is impossi- 
ble. Degeneration of tissue is usually secondary to atrophy, 
but sometimes occurs without previous atrophy. 

In pressure atrophy resulting from inflammatory con- 
traction, the process can not be controlled by any known 
method, no matter whether primary or secondary, but al- 
though the change is similar, if the atrophy is the result of 
impaired nutrition, the functions may be improved, provided 
nutrition can be restored. Ozena is sometimes a prominent 
symptom, with but slight change in the mucous membrane of 
the nose, still the offensive odor is present, and it will often 
be found that some of the accessory sinuses are affected. 

Atrophy from a Pre-existing Local Lesion. 

Etiology. — The atrophy is the result of inflammatory 
conditions which may be simple or infective. It may be 
from a rhinitis due to traumatism, a chronic or membranous 
type, or malformations of the structures of the nasal cavities. 
The hereditary tendency, frequently referred to, is usually 
due to the hereditary nasal structure, which favors inflam- 
matory action. Inflammatory action caused by, or following 



172 Nosk, Throat and Ear. 

infectious inflammatory processes, implicating the sub- 
mucosa, and producing permanent changes in the epithelial 
layer should be classed as exciting causes. 

Any systemic disease, as measles, scarlet fever, diph- 
theria, and sometimes enteric fever, may also be a cause. 
It may also be a sequelae of chronic catarrhal conditions of 
the accessory sinuses, or of a chronic purulent rhinitis. Age 
does not seem to be a factor, but it is most generally found 
under the age of thirty. The simple dry rhinitis of the aged 
is probably due more to senile than to true pathological 
changes. No micro-organisms which can be definitely 
ascribed as factors have been discovered, although several 
have been described as supposed causes. They probably 
are only adventitious. 

Pathology. — There is an excess of connective, tissue ele- 
ments of inflammatory origin which, following the rule of 
this structure, contracts. Prior to contraction, there is a 
chronic inflammatory process with organization. But when 
contraction commences, the circulation of the entire tissue 
is interfered with, the pressure involving the gland ele- 
ments as well as impairing nutrition, and atrophy results. 
In some cases there is thinning of the bony structure of the 
turbinates, especially of the middle and inferior, but this 
appears to be the result of constitutional rather than local 
causes. In the later stages of the disease the mucous mem- 
brane resembles cutaneous structure rather than mucous. 
The epithelium is scanty and cuboidal or flat in shape, and 
more or less granular debris is present as a result of desqua- 
mation and cell destruction. The basement membrane is 
not so much involved, but the submucosa is decidedly 
thinned and changed in structure. In the external portions, 
the glandular formations are partially or completely de- 
stroyed, the blood vessels lessened in quantity, or those pres- 
ent have decidedly thickened walls. There is more or less 
round-celled infiltration and granular debris. The deeper 



Atrophy from a Prk-existing Local Lesion. 173 

structures are fibrous, but not so decidedly contracted. Gen- 
erally the venous sinuses are obliterated. 

In infectious inflammatory processes, the pathology is 
similar, only there is primary involvement of the epithelial 
surface. The changes are more rapid. There is usually 
also implication of the glands of the posterior pharyngeal 
wall, as well as of the pharyngeal and faucial tonsils. 

Symptoms. — Usually a history of previous catarrhal 
symptoms, which, if complicated by nasal irregularities, will 




FlG. 61. View of left nasal cavity in atrophic rhinitis. 

increase the discomfort of the patient. As the atrophy 
progresses, the secretion will vary in quantity, and there is 
a tendency to form crusts. 

In the earlier atrophic stages the crusts are readily dis- 
lodged, but later they become more adherent, and are only 
removed by the use of considerable force. The annoyance 
caused by the crusts will often cause the patient to pick the 
nose, and the irritation thus produced is probably the cause 
of ulceration of the septum. The surface of the mucous 
membrane is irregular and the color varies. The areas in- 



174 Nose, Throat and Ear. 

volved in the process of atrophy are grayish or white, while 
the intervening tissue is boggy or edematous. The tissues 
generally affected are those of the anterior and middle por- 
tions of the middle turbinates and anterior portion of the 
inferior turbinates. 

An offensive odor is not always present, especially if 
the patient can keep the nasal cavities comparatively free 
from the accumulations, which will adhere to all portions of 
the tissue. More or less hemorrhage, generally the result of 
attempts to remove the crusts, may occur. The irritation in 
these "cases will usually produce a constant desire to free 
the nasal cavity, and there is often a sensation of an ac- 
cumulated secretion in the naso-pharynx, which is a reflex 
from the nasal condition. 

If of the infectious type, the secretion is profuse, muco- 
purulent, irritating and offensive. Not infrequently in 
these cases the post nasal space is involved through the ex- 
cessive secretion. When complicated with any accessory 
sinus disease, especially of the sphenoid, the odor is marked, 
and persists after thorough cleansing of the nasal cavities. 
The patient complains of dryness and irritation of the nasal 
cavities and naso-pharynx. Sometimes there is persistent 
itching of the anterior portion of the nasal cavities. The 
sensation of a foreign body in the nose is often complained 
of. The efforts to dislodge this will often loosen some of 
the incrustation, and it will be expelled, either through the 
anterior nares, or be drawn into the naso-pharynx and ex- 
pectorated. These dislodged masses vary in consistency, 
shape, and size, and usually are extremely offensive. At 
times the amount of secretion may be sufficient to occlude 
the nasal passages, usually being situated at the posterior 
portion. 

Pain, as a rule, is not present, although there may be a 
dull pain over the bridge of the nose, back of the eyeballs or 
in the frontal region. A dislike for mental activity is present 



Atrophy from a Pre-existing Local Lesion. 175 

and the patient often becomes pessimistic from worry over 
the condition producing the offensive odor. A hacking, 
persistent cough and hoarseness is often present. Disturb- 
ances of the alimentary canal are frequent, and a subnormal 
condition of the general system, as a result of the dyspeptic 
state. The special senses of hearing, smelling, and tasting 
are often impaired. 

In typical cases a peculiar facial expression is developed. 
The nostrils are widely expanded, alse thin and flat, and 
the sulci separating them from the cheek obliterated. A 
strumous appearance, with dull, expressionless face, thick 
lips, glands enlarged and some form of reflex rash on the 
face or nose may be present. 

Anterior inspection shows an enlarged nasal .space, and 
not infrequently the roofs of the nasal fossae and also the 
naso-pharyngeal walls may be inspected in this way. The 
tissue of the turbinates is reduced, and presents a shrivelled, 
shrunken, dry, glazed appearance. The color is pale, and 
the normal soft velvety sensation with a probe is lost. Pres- 
sure with the probe reveals a resisting surface which does 
not pit. Strings of inspissated secretion may be seen cross- 
ing from the turbinates to the septum, or the secretion may 
be in masses or crusts located in the affected areas. These 
may be offensive and closely adherent to the surfaces. 
When removed there is generally found an abraided surface, 
and some oozing of blood. The under surface of the crusts 
when removed will often show streaks of blood. In some 
cases the entire membrane may be covered with the dried 
secretion. When this condition occurs, the necessary manip- 
ulation for cleansing the cavities will cause the membrane 
to be darker in color, but this is only temporary, the charac- 
teristic pale appearance soon returning. 

Although a true ulcerative condition is infrequent, slight 
abrasions or superficial desquamation may show the loca- 
tion of dislodged crusts or mechanical interference on the 



176 Nose, Throat and Ear. 

part of the patient. The naso-pharyngeal mucous mem- 
brane partakes of the same characteristics and often the 
pharyngeal tonsil is more or less atrophied. 

Diagnosis. — The history of the case, and attention to 
the symptoms and appearances already mentioned. 

Prognosis. — Relief from the most unpleasant symptoms 
and odor can usually be given, but it is practically impossi- 
ble to restore the normal functions of the tissues. 

Complications. — Accumulation of secretion in the vault 
of the pharynx, and atrophic changes of the naso-pharyngeal 
tissues. Impairment of hearing through involvement of the 
Eustachian tubes, the morbid process extending through 
continuity of tissue. The accessory sinuses are often af- 
fected. Gastric disturbances and frequently reflex condi- 
tions may be present. 

Treatment. — Cleanliness is of the utmost importance. 
No unnecessary force should be employed in removing the 
crusts, as more surface may be denuded and the chances of 
ulceration increased. For cleansing the nasal cavities, the 
use of a warm alkaline solution, or the salicylic acid solu- 
tion. If the crusts are very tenacious, the employment of 
cotton tampons saturated with glycerine, allowed to re- 
main in contact with the tissues from ten to twenty minutes, 
will usually facilitate their removal, and the glycerine also 
appears to have a stimulating influence on the tissues and 
remaining glandular elements. If erosions of the surface 
present after the removal of the crusts, insufflations of boric 
acid or aristol should be used. It is a question whether 
decidedly astringent preparations should ever be employed 
in these cases. The offensive odor may be controlled in a 
measure by the use of potassium chlorate, or potassium 
permanganate. If anomalous conditions of the nasal struc- 
tures are present they should be corrected. 

Internally. — When the discharge is profuse, yellow, and 
thick, tonsils enlarged, naso-pharyngeal membrane thick- 



Secondary Atrophy from Other Lesions. 177 

ened, arsenic iodide. With a chlorotic condition, especially 
with pain in the frontal region, aggravated by motion and 
loss of smell, cuprum. A thick, offensive, tenacious dis- 
charge, often streaked with blood, or when the crusts leave 
an eroded surface when dislodged, potassium bichromate. 
If the patients have been loaded with mercury, potassium 
iodide. Marked and persistent excoriation of the nostrils 
and upper lip, particularly with a specific history, and en- 
largement of the lymphatics, phytolacca. The secretion 
purulent in character, lime. With an ulcerative tendency of 
the submucosa or periosteum, silicea. Thick, tenacious, 
hard crusts, forming especially in the olfactory region, 
thuja. The secretion moderately profuse, hydrastis. 

Secondary Atrophy Resulting from Other Lesions. 

Secondary atrophy is a result of lesions of other organs, 
and is produced by cyanotic congestion. 

Etiology. — Abnormal conditions of the nasal structures 
may in some cases be associated with the atrophy, but the 
primary cause is a diseased condition of some remote organ, 
as the heart, lungs, liver, or kidneys, which will produce 
venous stasis through interference of the venous circula- 
tion. The retardation is most marked in those structures 
which are lax, hence the mucous membranes are especially 
liable to be affected. Another important factor is the im- 
perfect elimination of waste products from the system in 
lesions of the urinary, alimentary, or respiratory organs ; the 
retained excrementitious material acting as an irritant, will 
manifest itself by inflammatory action. 

Pathology. — The submucosa is first affected. Nutrition 
is impaired, although there is an excess of blood to the 
parts. The excessive distention of the vessels causes 
atrophy of the perivascular structures through pressure, as 
well as through lack of nutrition. This necessarily pro- 
duces atrophy and degeneration of the epithelium. 



178 Nose, Throat and Ear. 

The tissues in this form of atrophy do not present the 
shrunken appearance found in typical atrophic rhinitis, but 
there is lessened' functional activity, though not always di- 
minished size of the tissues. 

The apparent enlargement is due to engorgement, while 
there is actually a diminution of the structural elements. 

Symptoms. — The mucous membrane of the septum, mid- 
dle and inferior turbinates, and occasionally of the superior 
turbinate, will be injected, tense and sodden. The charac- 
teristic symptoms of an acute inflammation may be present. 
The external tissues of the tip of the nose are often red- 
dened. Nasal respiration is usually markedly impeded, and 
generally there is an excessive exudation as a result of the 
over distention of the blood vessels. The voice has a nasal 
twang. Frontal headache is not infrequent, and a sensa- 
tion of fullness over the bridge of the nose, is often com- 
plained of. The ocular conjunctiva may be congested, and 
excessive lacrimation annoy the patient. The senses of 
smell and taste are impaired. A slight odor may be present 
but is not constant. 

Prognosis. — This will depend upon the causative lesion. 

Diagnosis. — A differential diagnosis must be made be- 
tween this type and intumescent, acute, and occasionally a 
chronic rhinitis. Palpation with a probe, careful inspection 
of the tissues, and the history, will all have to be considered. 

Complications— ^The accessory sinuses are at times im- 
plicated. The nasopharynx and rarely the larynx may 
present the same morbid appearance. When the naso- 
pharyngeal tissues are affected there is usually involvement 
of the Eustachian tubes with a consequent disturbance of 
hearing. 

Treatment. — Internal treatment in these cases must be 
for alleviating the morbid condition which is the cause of 
the local manifestation. 

Local treatment will be for keeping the nasal tissues free 



Purulent Rhinitis. 179 

from accumulated secretion, and also for relieving- the ob- 
structed respiration. As a cleansing solution the following 
will be found desirable: ^ — Acid salicylic (Lloyd's),- 3ss; 
sodii boras, ojss; Lloyd's hydrastis fl gi ; dist; hamamelis 
q. s. fl §jv. Sig. Teaspoonful in enough warm water to 
fill nasal syringe twice. For reducing the swollen, turgid 
tissue, tampons of cotton smeared with the salicylic acid 
ointment will be efficacious. The ointment is: I£ — Acid 
salicylic (Lloyd's), gr. xx; glycerine, q. s. ; white vaseline, 
§j. The acid is rubbed to a smooth creamy paste with the 
glycerine before the vaseline is added. This will make an 
ointment free from lumps. In using this ointment, the tam- 
pon of cotton should be allowed to remain an hour and then 
removed. The application should not be made to the same 
side of the nose oftener than twice a week. 

Purulent Rhinitis. 

Synonym. — Purulent nasal catarrh. 

This is an infrequent type. The nasal mucous mem- 
brane, through infection, secretes a purulent material. This 
does not include strumous rhinitis, or that resulting from 
injury or foreign bodies in the nose. It is usually a chronic 
condition. 

It may be the result of introducing the finger into the 
nose, after being in contact with an infected discharge. 

In the New-Born. — The condition may result from in- 
fection while passing through the parturient canal, or the 
introduction of irritative substances by careless washing of 
the child. In some cases, a purulent rhinitis may develop 
that can not be ascribed to any of these causes. 

Pathology. — Liquefaction-necrosis of the tissues results 
from the irritation of the infectious material similar to that 
found in abscess walls of other structures. The mucous 
membrane becomes practically pyogenic. 

Symptoms. — In this form of rhinitis there is a contin- 



180 Nose, Throat and Ear. 

nous discharge of a thick, tenacious, mucopurulent, usually 
bright yellow secretion, and generally from both nostrils. 
Slight febrile symptoms may precede the attack. The dis- 
charge is irritating and frequently excoriating, causing ex- 
coriation and ulceration of the upper lip. The infected 
area is confined to the anterior portion of the nasal passages. 
Respiration is but little if any interfered with. In severe 
cases the discharge may be through the naso-pharynx. There 
is very little odor unless the discharge becomes quite thick 
and remains for some time in the nasal cavities. 

Prognosis. — Even when recovery occurs, there is dimin- 
ished functional activity of the mucous membrane. 

Treatment. — Thorough, cleanliness must be insisted 
upon, and the alkaline wash followed by the salicylic acid 
wash will prove efficacious. If there is any odor, potassium 
chlorate or potassium permanganate should be used. After 
the tissues are clean, they should be carefully dried with 
cotton pledgets, and compound stearate of zinc with salicylic 
acid (mild), or the compound stearate of zinc with europhen 
insufflated. 

Internal medication should consist in the administration 
of lime. When the lymphatics or tonsils are enlarged, 
Phytolacca. In anemic individuals, arsenic iodide. In 
babies the use of inunctions of cod liver oil may be required, 
especially where there is a tendency to marasmus. Lime 
water should be given, and can be given with milk. 

Nasal Hydrorrhea. 

Synonyms. — Hydrorrhea nasalis ; Rhinorrhea. 

Etiology. — This obscure affection of the nasal tissues 
has.as a characteristic symptom, a profuse, thm, watery dis- 
charge from the anterior nares. The idea that it is the 
escape of cerebro-spinal fluid is held by some, while polypi 
or chronic catarrh of the antrum is the supposed cause by 



Nasai, Hydrorrhea. 181 

others. It may result as a reflex condition, but usually ap- 
pears to be the result of some systemic lesion in which the 
venous return is impeded. This produces a cyanotic state 
of the nasal tissue, which allows an escape of serum into 
the perivascular tissue, producing distention or edema. The 
escape of this infiltrated fluid by exosmosis, relieves the tis- 
sues temporarily. 

Pathology. — In three cases which the author has had 
under observation, the mucous membranes were edematous, 
and with an appearance as though a puncture would be fol- 
lowed by an escape of fluid. The color of the tissues was 
pale pink. On pressure with a probe the pitting slowly dis- 
appeared. A dull bluish-red or pale pink is the color usually 
found, similar to that seen in chronic congestion. Micro- 
scopic examinations of the tissue in these cases reveals small 
round celled infiltration into the submucosa, and relaxed, 
thinned vessel walls. The fluid contains simply an excess of 
inorganic salts. 

Symptoms. — During the paroxysm there is a constant 
dropping from the nose of a clear, transparent, colorless 
watery fluid. This may come without any warning, or be 
gradual, and will last from a few minutes to half an hour, 
excepting in very aggravated cases. There is usually sneez- 
ing preceding the escape of fluid, and at times headache. 
The attacks may or may not show a marked periodicity, or 
be nearly continuous. One case had the attack as soon as 
she arose in the morning, and the recurrence was about 
every half or three-quarters of an hour. She would use 
anywhere from ten to twenty handkerchiefs every day, but 
this was an aggravated case. Pain may be present, but is 
not a constant symptom. The discharge may be bland or 
irritating. The maximum of the attacks is usually during 
the waking hours, although cases which are worse at night 
are reported. Coughing spells or spasm of the glottis may 
result from escape of the fluid into the nasopharynx. The 



1 82 Nose, Throat and Ear. 

sneezing spells may be very severe. Constitutional symp- 
toms vary and should be carefully studied. 

Diagnosis. — The history, character of the discharge, in- 
spection, and palpation with a probe will make the diagnosis 
comparatively easy. 

Prognosis. — If the exciting cause can be determined and 
corrected, a cure will result. 

Treatment. — The local treatment that I have employed 
with good results in many cases, is the salicylic acid wash, 
used two or three times a day and the cotton tampons of 
salicylic acid ointment every second day. Internally, if no 
systemic lesions are present, distillate hamamelis and hydras- 
tis. In one case where the discharge was acrid and exco- 
liating, liquor potassii arsenitis was used. In the cases I 
have treated a cure was effected in from three to five months. 

Chronic Edematous Rhinitis. 

Synonyms. — Cyanotic rhinitis; Rhinitis sedematosa 
chronica. 

Etiology. — In nearly every case there is some morbid 
condition of the liver, and the concensus of opinion is that 
it is usually of hepatic origin. Morbid changes of the liver, 
kidneys, heart, or lungs which impede the circulation, and 
cause cyanotic congestion in remote tissues, are the prob- 
able causes of edema. Chronic edematous rhinitis may oc- 
casionally accompany asthma. It has also been classed as 
a neurosis. 

Pathology. — Infiltration of serum into the connective 
tissue causes swelling of the turbinates. The swelling may 
be migratory, local, or general. Obstruction of the vascular 
structures, either through engorgement or passive conges- 
tion, causes the swelling and not tissue proliferation. 

Symptoms. — The middle and inferior turbinates are af- 
fected with either intermittent or constant swelling, and 
interference of nasal respiration is commensurate with the 



Nasal Syphilis. • 1S3 

swelling. The location of the swelling varies. It may re- 
semble a cyst, causing pain, lacrimation, and an excretion 
of thin serum. If punctured, a thin serum escapes. Co- 
caine has but little contractile power on the enlargement. 
Ulceration may occur in the later stages. 

Diagnosis. — The symptoms given will determine. 

Prognosis. — This will depend upon the systemic cause. 

Treatment. — Compresses of cotton coated with salicylic 
acid ointment or glycerine may relieve the condition until 
constitutional remedies correct the cause. In some cases 
scarification may be necessary. Internally the use of chio- 
nanthus or chelidonium for hepatic engorgement. Apocy- 
mim, apis, or the two combined, in renal affections. Stro- 
phanthus, cactus, glonoin, digitalis, or Crataegus in cardiac 
lesions. Bryonia or asclepias in pulmonary diseases. In 
fact, the indicated remedy should be used. 

Specific Inflammations (Granulomata). 

(1) Syphilis, (a) Acquired; (b) Hereditary. (2) Tu- 
berculosis, (a) Lupus. (3) Glanders. (4) Leprosy. (5) 
Actinomycosis. (6) Rhinoscleroma. 

Nasal Syphilis. 

Synonyms. — Specific catarrh; specific rhinitis; syphilitic 
ozena ; syphilitic rhinitis. 

This is a local nasal manifestation of the constitutional 
disease. The disease may be acquired or hereditary. In 
the acquired form three stages are generally recognized, and 
it is infrequent for one to merge uninterruptedly into an- 
other, there being a stage of quiescence separating them. 

Acquired Syphilis. — In some instances syphilis may be 
contracted at birth or in utero, but as a rule a later period 
of life marks the initial lesion, especially after the age of 
puberty. 



184 Nose, Throat and Ear. 

Etiology. — Whether or not this disease is due to a spe- 
cial micro-organism, the bacillus of I^ustgarten, is a ques- 
tion, but that there is infection through an abrasion of the 
skin or mucous membrane is unquestioned. The disease is 
transmitted only by inoculation, and usually the initial lesion 
is located on the genitalia. The disease may be transmitted 
by kissing, as in one case under observation, a baby was in- 
oculated on the lower eye-lid of the right eye by being 
kissed by a woman who had mucous patches in the mouth. 
Infected surgical instruments, household utensils, or the 
passing "growler" or dipper used for drinking purposes by 
gangs" of workmen, may be the cause of infection. In 
some cases the initial lesion has occurred in the nose, usually 
by means of an infected finger. The Eustachian catheter has 
been responsible for a few cases of infection. 

As a rule specific manifestations of the nose are sec- 
ondary or tertiary lesions, the result of an initial sore on 
some other portion of the body. In persons of a strumous 
diathesis, or lowered vitality, the local symptoms are usually 
more pronounced and severe. 

Pathology. — Primary Stage. — An initial syphilitic 
lesion of the mucous membrane of the nose presents simi- 
lar appearances as in other localities. Varying from ten 
clays to six weeks after infection, a comparatively small, 
hjard, elevated, roundish, circumscribed papule, reddish or 
grayish-red in color, appears at the point of infection. As 
a rule this enlarges, a central necrosis soon follows; and a 
rather shallow ulcer forms, the floor and sides of which are 
fairly smooth. The ulcerative surface is covered by a thin 
glairy secretion. There is small round celled infiltration 
into the mucosa and upper portion of the submucosa. In- 
filtration of the vessel walls and sclerotic changes are pres- 
ent. In the later stages the usual degenerative pressure 
changes are observed. 

Secondary Stage. — The pathological changes of the 



Nasal Syphilis. 185 

coryza stage are similar to that of a simple catarrhal in- 
flammation, only the condition lasts longer, and resolution 
usually follows, so that there are slight, if any, evidences re- 
maining of a catarrhal condition. The mucous patches ap- 
pear as small oval or roundish papules, of a bluish-red color. 
They may be single, or multiple when they may coalesce and 
vary in size. Ulceration usually soon follows, forming a 
shallow ulcer, the edges slightly raised and surrounded by 
a more or less dark red zone. A grayish or creamy yellow 
pus bathes the surface. The pus, which is easily removed, 
will leave a raw-looking surface, which does not bleed easily. 
When the ulcerative surface is superficial, which is the rule, 
it will gradually heal, leaving slight evidences of an ulcer. 
When the ulcerative process has extended deeper into the 
tissues, a dense glistening cicatrix remains. 

The microscopic examination shows fluid infiltration and 
also small, round cells into the mucosa and outer portions of 
the submucosa. The epithelial cells are swollen, and there is 
an excess of fluid and small round cells. There is slight, if 
any evidence of organization, a partial gelatinous character 
of the cellular elements being found. A later stage will 
show desquamation of the epithelium,- fatty degeneration, 
disintegration, and liquefaction of the cellular elements, 
forming a more or less deep ulcer. At the margin, the epi- 
thelium shows a disposition to extend inward by prolifera- 
tion, and the adjacent tissues show an inflammatory condi- 
tion. Inhere is not much tendency to organization. At a 
still later period the healing process through cell prolifera- 
tion and reformation of epithelium is found, unless the ulcer 
is deep, when new tissue is formed and a fibrous cicatrix 
results. 

Tertiary Stage. — In the tertiary period the lesions are 
usually very destructive to tissue, the bony and cartilaginous 
structures being involved as well as the mucous tissues over- 
lying them. The submucosa is the first affected, gumma- 



1 86 Nosk, Throat and Ear. 

tous nodules or a diffuse inflammatory process developing. 
A diffuse thickening, or circumscribed areas of elevated, 
hard or soft, according to the stage, rounded ulcerations are 
formed. If uninfluenced by treatment, a fatty degeneration 
of the gumma occurs, with necrosis of the overlying tissue 
forming a deep, spreading, erosive ulcer, discharging a foul 
secretion, the result of vascular involvement. With proper 
treatment, a characteristic stellate cicatrix remains. 

Microscopically the gummata will be found composed of 
small round and epithelioid cells in masses, and near the 
margins, giant cells. Fibrous bands passing through the 
cell-masses may be found at an early stage. Inflammatory 
proliferation and fibrous formation will be found in the sur- 
rounding tissue. Thickening of the blood vessel walls soon 
occurs. Eventually fatty degeneration of the center of the 
gumma results, and the entire mass may present a deep sup- 
purating ulcer, or if infection is absent, organization of 
fibrous tissue may occur. Necrotic changes in the cartilages 
or bones may take place previous to, or at the time, or sub- 
sequent to the gummata, and may be extensive. These pro- 
cesses may start either from inflammation immediately ex- 
ternal to, or develop in the bony structure itself. 

Symptoms. — Primary. — The initial lesion may be on any 
portion of the mucous surface reached by an infected finger 
or^ instrument, the alse or septum being usually reported. 
The. lesion itself is painless, but a neuralgic pain as a result 
of its influence may occur. There is little or no difference 
between the lesion and a non-specific ulcerative papule in 
the same location. The symptoms being similar; more or 
less occlusion of the nasal space affecting respiration, olfac- 
tion, and phonation proportionately. Fever is occasionally 
present, and reflex disturbances may be noticed. The papule 
is circumscribed, firm and hard to probe palpation. Ulcera- 
tion soon follows. The size varies. If it is on the anterior 
part of the septum, it may entirely fill the vestibule, pre- 






Nasai, Syphilis. 187 

a 

venting inspection of the nasal cavity. The submaxillary 
glands are often implicated. They are somewhat enlarged 
and freely movable, but the enlargement is slow, they seldom 
attain much size, and are painless with but little tendency 
to suppuration, and specific treatment soon causes them to 
disappear. 

Secondary. — In a certain number of cases secondary 
manifestations occur in the nose, usually within six months 
of the initial lesion. In typical cases there will often be 
fever until the eruption appears, insomnia, restlessness and 
more or less shifting bodily pains. There is often anorexia. 
Symptoms of coryza, sneezing, lacrimation, photophobia, 
dull headache, impeded respiration, and disturbed olfaction 
and phonation may present. The secretion from the nose is 
profuse, being watery and thin in the earlier stages. 

Inspection reveals a red, swollen, and congested mucous 
membrane, sometimes edematous, especially of the middle 
turbinate. The coryza becomes more severe, with a thicker 
secretion which gradually becomes more or less fetid, and 
eventually is nearly or entirely purulent, with not infre- 
quently a slight amount of blood. The pituitary mem- 
brane, which is early covered with a thin secretion, 
shows areas that are disposed to spread and coalesce, 
and are covered with a greenish-yellow exudate. As 
the disease progresses, mucous patches may appear within 
the vestibule, or at the margins of the alye or septum. 
When they are found in the posterior nares, they appear 
as slight elevations of a purplish-red or ashy hue, ulcerated 
and generally covered by a yellowish exudate. These ele- 
vations are surrounded by inflammatory areas. The coryza 
is usually persistent unless specific systemic treatment is 
used. A valuable diagnostic aid in these cases is the cuta- 
neous eruption and rash. 

Tertiarv. — \\ nen the disease has been neglected, or im- 
properly treated, and reaches the so-called tertiary stage, 



1 88 Nosk, Throat and Ear. 

• 

the symptoms usually develop after the lapse of five or more 
years, even as late as twenty years. The mucous membrane 
slowly swells as a result of cellular infiltration and prolifera- 
tion. This swelling may be diffuse and cover a considerable 
surface, or may be circumscribed in nodules or gumma, 
occupying the respiratory region as a rule. The color at 
first is a reddish or purplish red, but finally becomes pale. 
In the early stages the swellings are firm and hard, and on 
pressure with a probe do not pit readily, but later they be- 
come softer. Pain is not a constant symptom, but when 
present is generally neuralgic in form, and is the result of 
the irritation caused by the presence of the growth. Im- 
peded respiration results, as in any other type of obstructive 
rhinitis. 

The course of the disease varies. Occasionally a condi- 
tion simulating atrophic rhinitis follows. There being necro- 
sis and absorption of the bony and cartilaginous tissues, but 
with no surface lesions or secondary infection, scar tissue 
followed by contraction increases the space of the nasal cavi- 
ties. The quantity of secretion is lessened, and becoming 
inspissated forms crusts, and the odor is marked. The 
sense of smell is lost, and the increased nasal space permits 
of free inspiration, but the inspired air is practically un- 
modified. As a rule ulceration ensues, the inflammatory 
tissues soften and ulcerate. The discharge becomes abun- 
dant, being frequently, dark colored, and possessing a pecul- 
iarly persistent foul odor, which it is almost impossible to 
modify. Dark yellowish or yellowish-green crusts, of in- 
spissated secretion cover the membrane and ulcerations. 
The destructive process slowly progresses and forms large 
suppurative foci, covered more or less by the crusts. Bone 
necrosis either occurs at this period or may have preceded it, 
and in the discharge will be found small, discolored, and 
offensive sequestra. Palpation with a probe will reveal the 
roughened surface, and often small fragments of necrosed 



Nasal Syphilis. 189 

bone will be dislodged. If the process continues until ex- 
tensive destruction of bony tissue occurs, there will be 
marked changes in the appearance of the face through the 
loss of support to the nasal bridge, the tip of the nose and 
the bridge both falling in and flattening, when the cartilage 
and vomer have been destroyed. There may be partial or 
complete destruction of the turbinates. Perforation of the 
hard palate may also occur. Complete destruction of the 
nasal tissues may follow in severe cases, leaving simply two 
openings in the face where the nose should be. Perforation 
into the cranial cavity may also result. 

Diagnosis. — Primary. — The initial lesion in the nasal 
fossae being so seldom found, renders a diagnosis difficult. 
Often its character is not positively known until secondary 
manifestations appear, although a careful inspection may 
reveal the peculiar characteristics of a true chancre. 

Secondary. — The nasal manifestations of this stage may 
be very slight. The history, general symptoms and cuta- 
neous eruption, together with the general improvement un- 
der specific treatment, will prove the character of the dis- 
ease. 

Tertiary. — In so-called tertiary lesions the characteristics 
are so pronounced that there is seldom any mistake in diag- 
nosis, the necrosis and foul, disgusting odor being pathog- 
nomonic. 

Prognosis. — In the secondary stage, prompt effective 
treatment usually results in a good recovery. Good results 
may follow in the tertiary stage, provided the destruction of 
tissue is not too extensive, and the recuperative powers are 
fairly good. The prognosis is less favorable when the necro- 
sis is considerable, and the tendency to rapid ulcerative de- 
struction of tissue is enhanced by feeble reparative powers. 
The length of time which elapses between the commence- 
ment of the necrosis and the commencement of treatment is 
also an important factor. 



190 Nose, Throat and Ear. 

Complications. — There may be necrosis into the cranial 
cavity, or the necrosis may invade the ethmoid, superior 
maxillary, sphenoid or even the occipital bone. 

Treatment. — Primary. — When the initial lesion is in 
the nose, it is necessary to keep the nasal surfaces as clean 
as possible. The use of the alkaline wash or salicylic acid 
wash will be effective. After the cleansing, an application 
of 1J — Thuja, Lloyd's hydrastis aa q. s., should be made 
with a brush of cotton. 

Neither cauterants of any kind should be used, nor ex- 
cision of the chancre. If there is enlargement of the lym- 
phatics, the internal administration of phytolacca is in- 
dicated. 

Secondary. — Local treatment is of little value for the 
coryza of secondary syphilis. Mucous patches should be 
treated with thuja, after cleansing the surfaces. In many 
instances the application of thuja alone has caused more 
rapid healing than the combination with hydrastis. It is 
seldom necessary to use silver nitrate in these cases, but 
occasionally it gives more prompt relief. The application 
is best made by fusing the silver salt on a roughened probe. 

Constitutional Treatment. — With swelling of the glands, 
Phytolacca is indicated. Iris may be combined with the 
Phytolacca when the lymphatic swellings are rather soft, 
ijmt when firm the phytolacca alone is better. Hydrastis is 
indicated whenever the mucous patches are present, or with 
a moderately profuse secretion. When the discharge is 
tough, tenacious, and stringy, and ulceration appears, give 
potassium bichromate. Potassium iodide in full doses 
should be given, but the effect should be kept just within the 
limit of iodisnr. In administering potassium iodide care 
must be exercised to avoid gastric irritation. The drug 
should be given after meals and at bed time, and in plenty 
of water. The patient' is directed to take not less than a 
glass of water with each dose. The various preparations 



Nasal Syphilis. 191 

on the market for preventing gastric irritation are inferior 
to copious draughts of water. The same rule holds with 
other drugs. The more effort made to disguise the drug, 
the more the patient eventually rebels against medicine. 
The water possesses valuable medical properties in increas- 
ing the amount of urine excreted, and as the syphilitic 
poison is eliminated largely by the excretory organs, it is of 
the utmost importance that these organs be kept in the 
best possible condition. Corrosive mercuric chloride or red 
mercuric iodide in small doses can be combined with the 
potassium iodide, or given separately as desired. It is not 
usually necessary to push these drugs to the limit, but simply 
to get the medicinal effect. 

Tertiary. — In the ulcerative process of this stage, the 
salicylic acid wash is a favorite, but the application of thuja 
afterwards should be thoroughly made. Care must be ex- 
ercised in all manipulations, as a fresh nidus for infection 
may otherwise be produced. In some cases the points of 
ulceration may require the solid silver nitrate, but not often. 
The cautery is seldom required, and the damage which may 
result in careless hands, is as bad as the original disease. 
When the deeper structures are involved, curettement and 
removal of loose bone is necessary. The odor may be par- 
tially modified by the use of potassium permanganate, grs. 
j-ij ; Aqua, 98 Fah. §j. Cleansing the nasal cavities every 
two to four hours, as necessary. The use of thuja should 
not be forgotten in the ulcerative condition. 

Constitutional. — Potassium iodide, corrosive mercuric 
chloride, red mercuric iodide, phytolacca, hydrastis, potas- 
sium bichromate, Donovan's Solution, gold and sodium 
chloride are the drugs usually indicated. 

Alcoholic liquors and tobacco must be interdicted. Pre- 
scribe plenty of out-door exercise, good food, and copious 
draughts of water. The excretory organs must not be al- 
lowed to become sluggish. If the cartilaginous support is 



192 Nose, Throat and Ear. 

destroyed, producing deformity, some mechanical appliance 
for restoring the contour of the nose will be required as soon 
as the destructive process is controlled, or the paraffin 
method may be used. 

In cases where there is not too much destruction of the 
soft tissues, the paraffin method is giving the most satisfac- 
tory results. The successful operation requires rigid aseptic 
precautions, the injection of a small amount of paraffin at a 
sitting, and the proper melting point of the material. Bad 
results can usually be traced to neglect of one of these essen- 
tials. There is danger, however, of embolism, even with the 
most rigid precautions, and embolism in the lung has been 
reported following this treatment, which should not be em- 
ployed unless the tissue is in a fairly healthy condition. 
Much cicatricial tissue is a positive contraindication, as well 
as an ulcerative state. 

The best syringe for the injection is Quinlan's, a con- 
stant flow of water at the proper temperature, n8°-i25° 
Fah. keeping the paraffin at the proper temperature. The 
paraffin must be thoroughly sterilized, and the skin at the 
point of puncture carefully cleansed, taking the same pre- 
cautions as for any surgical procedure. 

It is better to introduce only a small quantity at a time, 
repeating the operation, than to overdistend the tissues, as 
this may cause pressure necrosis. The paraffin can be 
moulded into the desired shape by manipulation with the 
fingers. Heat should be applied over the area to prevent the 
too sudden cooling of the material, gradually diminishing 
the temperature to the body temperature. 

Encapsulation by the formation of connective tissue 
around the paraffin mass results. 

Kyle gives the salient points of this method to be (i) 
Asepsis. (2) -Paraffin, melting point of 38 or 39 C. (3) 
Do not use too hot. (4) Introduce needle as far from de- 
pression as possible, carrying the needle subcutaneously to 



Hereditary Syphilis. 193 

the required spot. (5) Do not use too much paraffin; re- 
peated injections can be made. 

Hereditary Syphilis. 

Synonyms. — Congenital syphilis of the nose ; inherited 
syphilis of the nose. 

This term is applied to syphilitic infection in utero. The 
disease may manifest itself before the third month, or it 
may* not appear until near the age of puberty. The former 
is usually classified as secondary and the latter as tertiary. 
The term snuffles is applied to the early form, and syphilis 
tarda to the latter form. 

Etiology. — Transmission through the parents. If the 
father, sperm-inheritance, and if the mother, germ-inherit- 
ance. Not infrequently there is a combination of the two. 
In those cases where inoculation occurs during the passage 
through the parturient canal, it is acquired syphilis, not 
hereditary. 

Pathology. — Early. — The pathological conditions are 
similar to the secondary acquired form, but are liable to be 
intensified, and as the nasal chambers are small, more 
marked destruction of tissue may result. There may be 
necrosis and absorption of bone and cartilage as a result of 
deep inflammation. The flattened nasal bridge usually re- 
sulting from this form is probably due to lack of develop- 
ment, depending upon the reaction following the inflamma- 
tory condition. 

Late. — Identical with the so-called tertiary lesions of* 
the acquired disease. 

Symptoms. — Early. — Seldom earlier than the second or 
third week, and infrequently later than three months, a 
severe rhinitis is noticed. The nasal mucous membrane is 
reddened and swollen. There is a copious, clear, watery 
discharge, irritating and excoriating. As the process con- 

13 



194 Nosk, Throat and Ear. 

tinues the character of the discharge changes, becoming 
muco-purulent, thicker and with a tendency to crust forma- 
tion. In severe cases, ulceration and necrosis may occur, 
and the discharge becomes purulent, mixed with blood and 
shreds of necrosed tissue. The characteristic odor is no- 
ticed. At the angles of the alse and nasal margins, fissures 
appear. The breathing becomes noisy on account of the in- 
terference of nasal respiration, hence the common name 
"snuffles," and the child commences to breathe through the 
mouth. As a result of the impeded respiration the child 
has difficulty in nursing, and during sleep "suffocative 
spasms" are not infrequent. Mucous patches at the angles 
of the nostrils and on the nasal membrane are often present, 
and occasionally necrosis of the bony or cartilaginous nasal 
structures follows. The flattening of the nasal bridge is 
pathognomonic and is evidently due to non-development, 
through inflammatory interference with tissue growth. 

The constitutional disturbances are marked, either at 
birth or soon after. The child is ill-nourished and weazened. 
This condition becomes more marked through the inability 
to nurse properly, and the inhalation of the foul odors and 
swallowing of the fetid secretions still further impair 
vitality. The skin has a sallow, muddy, unhealthy hue, and 
various lesions may be present. Mucous patches are fre- 
quent, especially at the muco-cutaneous junctions. The 
hair and nails are also included in the general degeneracy. 
Restlessness, yawning, fitful sleep, and a gradually ac- 
quired shrill pitch of the voice are also important symptoms-. 

Late. — The usual conditions of the hereditary form 
which appears between the third month and puberty, do not 
differ materially from the tertiary acquired form, so will 
not be repeated. 

Diagnosis. — Early. — The symptoms of this form are 
usually pathognomonic. The coryza, appearance, and ex- 
pression of the face, parental history when obtainable, and 



Hereditary Syphilis. 195 

unyielding to treatment excepting specific, will make the 
diagnosis certain. 

Late. — Easy as a rule. The history of the case, pro- 
gressive destruction of nasal tissues, peculiar horrid odor, 
and the amelioration of the conditions under specific treat- 
ment all point to the character of the disease. In some in- 
stances lupus may be confounded with syphilis, but lupus 
is seldom a primary disease of the nasal cavities, but ex- 
tends usually from the face. Lupus is also slower in its 
destructive process, attacks cartilaginous structures and not 
bony, so does not affect the hard palate, and the odor is 
not so offensive. 

Prognosis. — Early. — As a rule, the sooner after birth 
the disease manifests itself, the less favorable the prognosis. 
The general severity, and the vitality of the child are also 
important factors. When nutrition is fairly good, and the 
child has an average amount of vitality, yielding quickly to 
proper treatment, the prognosis is fair in the milder cases. 
In those cases where these conditions are reversed, the 
chances are against recovery. The transmission also ap- 
pears to be an important factor also, as it seems the death 
rate in sperm transmission is a little over 25 per cent ; germ 
transmission nearly 60 per cent ; and 70 per cent when both 
parents are infected. 

Late. — The strength of the patient, the severity of the 
manifestations as regards necrotic changes and the time of 
commencing treatment, largely determine the results. The 
earlier treatment is begun, especially before there is much 
destruction of tissue, the better. 

Treatment. — Local. — Cleanliness of the nasal surfaces 
is absolutely necessary, but in very young children is diffi- 
cult to obtain. Small rolls of blotting paper may be em- 
ployed to remove the excessive amount of secretion, or the 
child may be made to sneeze, which will often cause ex- 
pulsion of considerable secretion. The nasal syringe can 



196 Nose:, Throat and Bar. 

be used in many cases, using the salicylic acid wash, or an 
alkaline solution, especially when there is formation of 
crusts. .After the surfaces are clean, any ulcerative points 
should be touched with thuja and hydrastis. This may be 
done with cotton wrapped on a probe or the solution may be 
warmed and dropped into the nose with a medicine dropper. 
The same care must be exercised as in adult cases not to 
abrade unaffected tissue, as this will give a fresh nidus for 
infection. For the offensive odor the potassium permanga- 
nate solution should be employed. In some cases the atom- 
izer can be used better than any other method. The douche 
in these cases should never be employed. 

Constitutional.— Potassium iodide, gold and sodium 
chloride, potassium bichromate, etc., and such other reme- 
dies as are indicated. 

Nasal Tuberculosis. 

Synonyms. — Nasal phthisis ; Tuberculosis nasalis ; Phthi- 
sis nasalis. 

This is fortunately an infrequent disease. It is a chronic 
infectious inflammation. There are either the characteristic 
tubercular ulcers of the mucosa, or tubercles forming 
tumors which eventually break down and ulcerate. Both 
of these conditions may be present at the same time. 

The nasal secretion is increased and fetid. The disease 
is essentially chronic, and is modified little, if any, by treat- 
ment. 

Etiology. — Predisposing causes: in the majority of cases 
there is a tubercular diathesis. Most frequently the disease 
is a secondary infection from tubercular lesions in other 
par£$ of the body. Abrasions of the nasal mucous mem- 
brane and lowered vitality are important predisposing fac- 
tors. Malformations of the nasal cavities from any cause 
have also been ascribed as factors in causing this disease, 
as, through. retention of secretion, the resistance of the parts 



Nasal Tuberculosis. 197 

is diminished, and the liability of infection increased. 
Whether the disease is contagious has not been definitely 
decided. 

Exciting Causes. — The bacillus tuberculosis is now 
quite generally conceded to be the direct cause of the dis- 
ease. In a very few instances has primary infection of the 
nose occurred, as actual contact of the infection upon an 
abraded surface appears necessary. 

The action of the nasal secretion is to carry away all 
deleterious material, thus lessening the liability to primary 
infection, unless there is an open lesion of the mucous sur- 
face. 

Secondary infection may occur through the blood circu- 
lation, lymph channels, continuity or contiguity of struc- 
tures. As a rule it results from infection of the lower res- 
piratory tract, the infected material coming in contact with 
abraded nasal surfaces during violent paroxysms of 
coughing. 

Pathology. — The macroscopic appearance may be that 
of a diffuse swelling from a general tubercular infiltration; 
or miliary nodules may be present, which sometimes coa- 
lesce, forming a single growth. In either form the nutrition 
is eventually interfered with, and liquefaction-necrosis re- 
sults, then ulceration and mixed infection, which is followed 
by typical tubercular ulcers. 

The ulceration spreads slowly, and often the floor and 
margins present small miliary tubercles : these softening and 
breaking down increase the ulcerated area. As a rule, 
there is more or less inflammatory uction surrounding the 
ulcerated areas. 

Microscopic. — Small round lymphoid cells are numer- 
ous, as well as many epithelial cells and some giant cells. 
The tubercle bacilli are not usually numerous. The tend- 
ency of the cells is to form masses, which, through pro- 
liferation, increase in size and cause considerable pressure 



t9$ Nose, Throat and Ear. 

which mechanically interferes with the blood supply, event- 
ually obliterating it entirely; liquefaction-necrosis, and ul- 
ceration follow. The glandular structures are involved 
through the pressure of the infiltrate ; distortion, obliteration, 
or desquamation of the secretory epithelium being found. 
The collection of the infiltrate acting as a foreign body, 
causes the surrounding tissue to show inflammatory condi- 
tions. The size of the tubercular tumor varies from the 
size of a pin-head to that of a large pea. The growth is 
slow, and the appearance depends upon whether in the 
progressive or retrogressive stage. In the early stage the 
growth is firm to touch with considerable hyperemia, but 
later becomes softer and paler. The base of the tubercle is 
usually broad, and there is a zone of redness surrounding it. 

The pathological process is similar to that of other re- 
gions, modified somewhat by its location. Partial absorp- 
tion of the infiltrate may follow when caseation results. 
Generally the overlying tissue breaks down, and discharge 
of the cheesy contents, together with pyogenic infection, 
produces the typical tubercular ulcer. In some instances an 
attempt at healing is made, and proliferation and organiza- 
tion of inflammatory tissue into fibrous cicatrices results. 
This formation is very liable, however, to tubercular de- 
generation at a later stage. As a rule, fibrous thickening 
in the tissue surrounding the tubercle occurs. 

Symptoms. — As the disease is usually secondary, there 
will be found more or less systemic disturbances, according 
to the extent and severity of the primary disease. On this 
account a varied range of symptoms may present them- 
selves, from slight evidences of hereditary tendency, to 
emaciation, hectic flushes, racking cough, and extreme ex- 
haustion. The rhinitis is insidious in its onset. In the ul- 
cerative form, a small ulcer, usually on the anterior portion 
of the septum, will be seen. This spreads slowly and grad- 
ually over the septal surface to the floor of the fossa, but 



Nasai, Tuberculosis. 1 9$ 

seldom to the turbinates. Occasionally it may extend to 
the upper lip. The ulceration is round or ovoid, the edges 
irregular and uneven, sometimes slightly raised. The floor 
is rough, and contains grayish or yellowish broken-down 
tissue. Caseating tubercles may also be present, either on 
the floor or margin of the ulcer. Perforation of the septum 
may occur. Secretion is increased, and is mucoid or muco- 
purulent, and more or less offensive. Occasionally there is 
crust formation, and the forcible removal of the crust is 
followed by slight hemorrhage. Pain is almost entirely ab- 
sent in this disease. There is but slight, if any, disposition 
to heal, and if healing does occur, it is only temporary. 

In those cases where the tubercular neoplasms are char- 
acteristic, the rule is for the turbinates to be affected. The 
tumors varying in size cause more or less obstruction to 
respiration. The shape also varies, but generally is irregu- 
larly rounded ; the surface may be smooth, granular or 
nodular. The base may be broad, and the color vary from 
a gray or pale pink to dark red, or in the later stages, yel- 
lowish or whitish. Occasionally there is pallor of the 
mucous membrane. Hemorrhage may result from very 
slight irritation, or from no apparent cause. The tumors are 
firm and hard to touch in the early stages, but later there 
is often softening in the center with the periphery hard, and 
at. last the entire nodule softens, ruptures, and discharges, 
forming a tubercular ulcer, similar to that of the first form. 
The nasal secretion is moderately increased, assuming after 
ulceration the characteristics already described. 

There is absence of pain, and the only annoyance usually 
complained of, is the impeded nasal respiration, which may 
be complete. The same stubbornness to healing is present 
as in the first type. Removal of the tumor will leave a trau- 
matism, which heals very slowly, and with a tendency to 
recurrence. Granulations filling the nasal cavities have been 



2oo Nosk, Throat and Bar. 

reported in a few cases. Both forms may occur at the 
same time, and one or both sides may be involved. 

Diagnosis. — The only positive proof is the finding of 
the tubercular bacilli in the secretion or growth. Tuber- 
cular manifestations in the oropharynx, larynx, or lungs, 
and a history of hereditary predisposition, are also impor- 
tant. Syphilitic lesions are eliminated by the history, gen- 
eral symptoms and reaction to antisyphilitic treatment. In 
some cases both conditions may be present at the same time. 
Malignant growths are usually more rapid in growth, and 
generally painful, and the age of the patient is of diagnostic 
value. 

Prognosis. — Not favorable as regards a cure. The dis- 
ease usually is extremely Chronic, extending over a period 
of years, but is the least fatal of any of the tubercular man- 
ifestations. As a complication of tuberculosis in other 
respiratory regions, it may hasten death. As a predisposing 
factor in many infectious and systemic diseases, it plays an 
important part. 

Complications.— As a result of impaired resistance 
through both local and systemic infection, the tissues are 
especially liable to other pathologic changes. 

Treatment. — Cleanliness of the nasal tissues is im- 
portant. The use of both an alkaline wash and the salicylic 
ajcid solution is beneficial. Tubercular formations should be 
removed by means of the snare or scissors, and their bases 
touched with chromic or salicylic acid. Ulcerative areas 
should be curetted, and usually a 50 per cent lactic acid is 
used over the entire traumatism. When operative meas- 
ures are employed they should be radical, as otherwise 
there will be a rapid dissemination of the disease. Pain 
is not often present, but when it is, it may be relieved by 
the use of the chloretone inhalant. The general systemic 
condition must be brought to as near normal as possible. 
Out-door life is of the utmost importance. When there is 



Lupus, 201 

increased temperature and pulse, veratrum and liquor 
potassii arsenitis should be employed. Fatty foods, plenty 
of rich milk and good butter are pleasanter than cod-liver 
oil, and much less liable to disturb the stomach. 

Lupus. 

Lupus of the nasal mucous membrane is seldom primary, 
but usually secondary to that of the face. Small elevated 
nodules, with a disposition to coalesce and later ulcerate, 
characterize this disease. In some cases absorption may 
occur, which is later followed by atrophy. 

Etiology. — The generally accepted view that lupus is 
essentially a tubercular disease, seems plausible on account 
of the course and character manifested. The victims of 
this disease nearly always present a tubercular history. For- 
tunately the disease is not prevalent. The claim is made 
by some that females are more frequently affected than 
males, and that it is oftener seen in inhabitants of the coun- 
try than of cities. The time of the first manifestation is 
usually before middle age, but may occur at any period of 
life. Abrasions or atonic conditions of the mucous mem- 
brane are probably predisposing factors. There does not 
seem to be any hereditary transmission of lupus. 

Pathology. — When the disease is primarily of the nasal 
mucous membranes, the anterior portion of the septum just 
within the nostrils is the usual site of invasion, spreading 
as a rule across the nasal floor to the turbinates. If the 
disease extends from the face, the lateral cartilages are in- 
volved. The bony structures are seldom, if ever, impli- 
cated. Hamilton claims the lymphatic system is sometimes 
affected, but there is not often implication of distant tissue. 
Small nodes, either single or multiple, mark the onset of 
the disease. These increase in number, with coalescence, 
finally producing slightly elevated, nodular surfaces. The 
nodules are small, hard, and circumscribed, and the over- 



202 Nose, Throat and Ear. 

lying tissue hyperemic, traversed by tortuous and congested 
blood vessels. The nodules may finally become paler in 
color, and when ulceration occurs, light brownish flakes of 
inspissated secretion may cover the surface. As a result of 
obliterated blood-supply, degenerative changes take place 
in the nodules, causing ulceration and discharge of necrosed 
and liquefied tissue, forming an oval or round ulcer, the 
margins of which are indurated, presenting a shallow, cup- 
shaped depression. Perforation of the cartilaginous sep- 
tum may follow. The necrosis in these cases is usually ser- 
piginous in character. The nasal floor and turbinates may 
be involved, especially the middle turbinate, but the bony 
structure is not affected as is the cartilage. 

Histologically, a differentiation from tubercular disease 
can not be made. In the fully developed nodule will be 
the central giant cell, numerous small cells and peripheral 
epithelioid cells. Tubercule bacilli are usually found in this 
disease. The adjoining tissue shows more or less inflam- 
matory action. Mucoid change and fatty degeneration ap- 
pear later, but preceding ulceration. The lower parts of 
the mass generally show marked cellular fatty-degeneration 
absorption. Occasionally the disease does not follow the 
ulcerative course, but on reaching the nodular develop- 
ment stage undergoes degenerative changes, the nodule 
eventually being absorbed and leaving r fibrous tissue cica- 
trix, which finally is followed by atrophic changes. 

Symptoms. — One or both nasal cavities may be affected. 
Occlusion of one or both sides by the nodular growths may 
occur. Frequently it is impossible to examine the deeper 
portions of the nasal cavities, and the middle turbinates may 
be entirely concealed. The secretion is slight, at first clear, 
becoming thicker as ulceration progresses, and if retained 
for some time in the nasal cavity, putrefactive changes 
occur, causing the secretion to be somewhat fetid. Grayish 
or dark colored scales or scabs usually form over the lesion, 



Lupus. 203 

which are more or less tenacious. Detachment of these 
crusts is often followed by oozing of blood. 

When inspection of the nares is possible, the character- 
istic small nodules may be seen, usually on the septum 
These nodules are more irregular in outline than in 'the 
cutaneous form. In the early stages of development the 
nodules are firm and hard to the probe, but later, when they 
soften, the probe readily penetrates the mass, and may even 
pass through the cartilage, producing a slight hemorrhage. 
While the growths are generally painful to touch, • their 
presence and growth seldom cause much pain. When the 
ulcerative type presents, the serpiginous form of spreading 
is seen. The ulcerative process is essentially chronic, and 
may cause perforation of the septum. The external ap- 
pearance of the nose is changed, being pale, rigid, and later 
pinched and shrunken looking, as cicatrization progresses. 
When there is a simultaneous destruction of the integument, 
extensive ulcerations and erosions present, leading to ex- 
treme deformity, or sometimes even stenosis, from the re- 
sulting cicatrization. There is in some cases considerable 
itching. Lupus exedens is usually applied to the ulcerative 
form, and non-exedens when ulceration does not occur. In 
the latter form there is not the extension of the disease that 
occurs in the former. 

Diagnosis. — Generally easy, if the symptoms described 
are remembered. Syphilis is differentiated by the history, 
intermittent periods, bone involvement, and amelioration by 
specific treatment. Malignant growths usually develop more 
rapidly, are painful and generally appear later in life. 
Fibroma are usually firmer and not easily torn. Mucous 
polypi are smooth, soft, glistening, and generally pedun- 
culated. Nasal tuberculosis nodules are not irritable to 
touch, and the extension is different, while reparative tend- 
encies are rare. 

Prognosis. — Unfavorable regarding a cure or prevention 



264 Nose, Throat and Ear. 

of deformity, but it is seldom fatal. The disease is essen- 
tially chronic in its course, and may sometimes be checked. 
Spontaneous recoveries have been reported. 

Complications. — Erysipelas has been reported, and any 
of the infectious conditions may be contracted through the 
denuded surfaces. 

Treatment. — Local. — Thorough extirpation of the 
lesions. After anesthetizing the mucous surface, the crusts 
should be removed, and by curettage, the morbid tissue, in- 
vading also some of the surrounding healthy tissue, then 
using 60 per cent lactic acid or strong carbolic acid over 
the traumatic surface. Cleanliness of the nasal surfaces 
can be obtained by the use of the salicylic acid solution, 
followed by the application of stearate of zinc with salicylic 
acid. 

Internally. — Phytolacca, liquor potassii arsenitis, syrup 
of calcium lactophosphate, hydrastis, nux, etc., should be 
given. 

Glanders. 

Synonyms. — Equinia ; Maliasmus ; Malleus ; Malleus 
humidus. 

An exceedingly contagious disease of horses, not often 
transmitted to man. When it is, there are severe constitu- 
tional symptoms, and formation in the submucosa of the 
infected mucous membrane of granulation-tumors, which 
soon ulcerate, and are accompanied by an offensive dis- 
charge. As a rule, the nasal mucosa is first affected. The 
progress of the disease is rapid, and usually fatal. Either 
acute" or chronic conditions may occur. The manifestation 
of the disease in the respiratory tract only is considered. 

Etiology. — In 1882 Loeffler found the bacillus mallei, 
which is recognized as the cause of glanders. The disease 
is most frequently found among horses, but is sometimes 
transmitted to man. Cases have been reported where the 
disease has been communicated from one person to another. 



GLANDERS. 205 

/The disease is most frequently found among people who are 
employed about horses. The invasion of the disease seems 
to depend upon an abrasion of the skin or mucous mem- 
brane, although cases have developed where this does not 
seem to have occurred. It is at times difficult to obtain a 
satisfactory history. 

Pathology. — In this disease numerous scattered or closely 
grouped granulation tumors are found on the nasal sub- 
mucosa. The lymph structures are invaded, and their loca- 
tion is determined by the new formation. Whether the 
irritation is caused by the presence of the bacilli, or by the 
products of the germs, has not been definitely settled ; but 
there is a proliferation of leukocytes forming lymphoid cells, 
and an ever-increasing number of the bacilli. Nutrition is 
arrested, and commencing at the center of the mass, lique- 
faction necrosis results. When this occurs, rupture of the 
tissues follows and there is a discharge of puruloid secre- 
tion over the surface of the mucous membrane. Small 
abscesses, or ulcers, result, which vary in size. Micro- 
scopical sections will show the tumor to consist mostly of 
epithelioid and lymphoid cells, numbers of bacilli, and some 
fibrous structure. Two forms exist, the acute and chronic. 

Symptoms. — The chronic form is neither as frequent nor 
as rapid as the acute, but the chronic usually terminates in 
an acute type. In the chronic form the membrane becomes 
swollen and often painful, and is covered with dirty, crusty 
scabs. There is more or less viscid, mucopurulent fetid dis- 
charge, which becomes serous as the ulceration progresses. 
The cutaneous surface is implicated, and there is either the 
development, maturation, and discharge of subcutaneous 
nodules, or the superficial formation of bullae. Extensive 
lymphadenitis and lymphangitis result, and the extent of 
the suppuration will produce an irregular fever. The 
deeper structures are destroyed, there is ,also necrosis of 
the bone and cartilage, with escape of necrosed material and 



206 Nose, Throat and Ear. 

gangrene of the surrounding structures. When the acute 
form does not terminate the attack rapidly, the patient be- 
comes emaciated, profuse sweating occurs, colliquative diar- 
rhea with exhaustion follows, and finally, death from col- 
lapse. 

In the acute form, the symptoms are those of an acute 
infection; lassitude, rigors, rheumatic-like pains in the 
trunk, back, extremities and joints, besides headache, dysp- 
nea, irritation of the stomach with nausea and vomiting, and 
finally diarrhea. The infected site becomes hot, red, and 
swollen, lymphangitis soon occurs and the surrounding 
structures swell and redden. Small nodules form in the 
submucosa, which, from a translucent appearance, become 
darker, then yellowish, eventually rupturing. A thick, semi- 
fluid deep yellow, frequently blood streaked, offensive dis- 
charge follows. The ulcerative process shows little tend- 
ency to heal. The cutaneous surfaces become involved in 
a similar manner. Enlargement of the lymphatics, espe- 
cially of the neck, rapidly follows. Constitutional disturb- 
ances are marked, temperature increased, pulse rapid, tongue 
dry and coated with a whitish fur. A typhoidal condition 
soon occurs, emaciation and exhaustion from the profuse 
sweating, nausea, vomiting, and frequent diarrhea, until 
death results. 
J Diagnosis. — The positive diagnostic test is the recogni- 
tion of the bacilli mallei, or by inoculation of susceptible 
animals, as the guinea pig, rabbit, or mice. The occupa- 
tion of the patient will often aid in the diagnosis, as stable- 
men run greater risks of infection than others. The dis- 
ease may simulate typhoid, but lacks the rose spots. Pyemia 
or malignant growths may be difficult to distinguish from 
this disease. The diagnosis should always be by exclusion. 
Prognosis. — Always guarded. Some cases are reported 
as having recovered from the acute form, but death usually 
results, generally within a few days. In the chronic form 



Leprosy. 207 

with skin complications, the result is usually fatal. Al- 
though some recoveries occur, death results usually in from 
six to eight months. 

Complications. — In man, as in' the horse, a subacute 
pneumonia may result. 

Treatment. — For the nasal condition, opening and curet- 
ting the nodules, abscesses or ulcers, and cauterization of 
infected parts, and the removal of all suspicious growths. 
The cauterization may be made with carbolic acid, carefully 
applied to the affected area after curettage. A solution of 
potassium permanganate, or the salicylic acid wash, may 
be employed to keep the nasal surfaces as clean as possi- 
ble. The constitutional symptoms should be met with aco- 
nite or veratrum, for the fever; phytolacca or iris, or both 
combined, for the lymphatic disturbance ; baptisia, echinacea, 
or potassium chlorate, for the evident septic state ; potas- 
sium bichromate for the ulcerative condition and tenacious 
secretion. Potassium iodide has been reported curative in 
some cases, giving the drug in large doses. 

Leprosy. 

Synonyms. — Elephantiasis Grsecorum ; Lepra. 

In this country, leprosy is sefdom seen. The nasal, 
pharyngeal, or laryngeal invasion occurs as complications 
of the systemic infection. Two forms are recognized, the 
anesthetic and tubercular. 

In the first variety, there are anesthetic areas caused by 
neuritis of the connected nerve supply, followed by tropho- 
neurotic changes. 

In the tubercular variety there are local granulation- 
tissue masses in the submucosa, which undergo liquefaction- 
necrosis and ulceration, the ulcers showing a variable tend- 
ency to cicatricial healing. 

Etiology. — This disease is supposed to be caused by the 
bacillus leprae. Leprosy is most frequently seen in the Sand- 



208 Nose, Throat and Ear. 

wich Islands, China, and India, the majority of cases being 
between fifteen and thirty years of age. The disease is but 
slightly Contagious, and the exact method of inoculation is 
not understood. It appears to be as varied in the manner 
of transmission as syphilis. Heredity is probably an im- 
portant factor. 

Pathology. — Both the anesthetic and tubercular varieties 
may co-exist in the. same patient. In the first form, there 
are changes in the nerves supplying the affected areas. The 
nerves show, by microscopical examination, a chronic inter- 
stitial neuritis. When the nerve influence is destroyed, 
atrophic changes occur, the anesthetic areas ulcerate, mus- 
cle and glands atrophy, and necrotic bone is discharged. In 
the tubercular form the lesion is characteristic, and cer- 
tainly places the disease among the infectious granulomata. 
At the point of infection, there is an inflammation which is 
followed by infiltration and proliferation of the cellular ele- 
ments, and the formation of a granulation tumor. 

Symptoms. — As a rule, the disease of the respiratory 
tract is secondary to the cutaneous and constitutional condi- 
tion. The anesthetic form is reported not to manifest itself 
under five years from the time of the onset of the disease. 
Complete anesthetic areas are found in the nose and 
pharynx ; the soft pajate is not sensitive, and motor paralysis 
of the larynx sometimes occurs. Ulceration, and later ab- 
sorption of the nasal bones follows. The nodules in the 
tubercular form follow the same course of development as 
those of the skin. First, the erythematous stage, in which 
the mucous membrane reddens, is hyperemic, and often 
there is epistaxis. Eventually the membrane pales and 
thickens. There is the appearance of a thin transparent 
coating over the mucous surface, and the sensibility to 
odors and touch is lessened. Respiration may be interfered 
with through the thickening, and in those cases where the 
pharynx and larynx are also affected, the effort to talk will 



IyEPROSY. 209 

quickly produce fatigue and dryness of the throat, the voice 
gradually assuming a nasal character, then shrill, and finally 
aphonia. In the second stage there develops in the in- 
flamed areas numerous small nodular masses, which may 
continue discrete, or coalesce. These producing pressure 
atrophy of the glandular elements in the overlying tissue, the 
surface will present a smooth, tense, and glistening appear- 
ance. The respiration is still impaired. The duration of 
this stage is variable, extending from a few weeks to sev- 
eral months, or it may be final. In the third stage, the 
nodules soften, open, and form small ulcers. Pyogenic in- 
fection results, the discharge thickens, is yellowish or brown- 
ish, is nearly always offensive, and there is a disposition to 
crust formation. The ulcers increase in size and produce 
facial changes, similar to those seen in tertiary syphilis. 
Atrophy and disintegration of the turbinates results, per- 
foration of the septum, and often of the hard palate. The 
entire framework of the nose is weakened, and flattening or 
collapse of the nose follows. The soft palate is frequently 
destroyed. When cicatricial bands form, they, by their con- 
traction, produce still more distortion of the structures. 

Diagnosis. — Usually easy, as the cutaneous condition 
will eliminate other diseases. Tertiary syphilis is differen- 
tiated by the history and amelioration by specific treatment. 

Prognosis. — The same as for the general disease. The 
anesthetic form runs its course in from fifteen to twenty 
years, and the tubercular in from eight to ten years. Spon- 
taneous recoveries sometimes occur, and cures are not in- 
frequently reported. 

Treatment. — So far, any one line of treatment has proven 
unsatisfactory. Ingals claims some cases were improved 
by the use of chaulmugra oil, 5 to 60 drops a day, taken 
internally, and inunctions of the same, one part to five or 
six parts of lard. 



210 Nose, Throat and Ear. 

Nasal Actinomycosis. 

This disease may occur in the nasal mucous membrane, 
but so far, no cases are known. The probabilities are that 
it has not been recognized, as even the pharyngeal form is 
often unrecognized. The description of the pharyngeal dis- 
ease will suffice for such cases as may occur. 

Rhinoscleroma. 

Rhinoscleroma is seldom seen. Firm, hard, nodular 
tissue, with a tendency to lateral extension, is formed in 
the submucosa or deeper layer of the cutaneous structure. 
There is no pain, no discharge, and seldom, if ever, ulcera- 
tion. Systemic symptoms are absent, and the growth is 
very slow in development. The cause is not positively 
known. 

Etiology. — At the present time a bacillus is credited with 
being the cause, the bacillus of rhinoscleroma. There seems 
to be no predisposing factor. The disease appears to be 
most frequent in Southeastern Europe, and the ages range 
from fourteen to forty-five. 

Pathology. — There is a round celled infiltrate into the 
corium and papillae if the formation is in the skin, or in the 
submucosa if in the mucous membrane. Histologically the 
lesion shows fibrous tissue and small round cells, large 
spherical, hyaline cells with a protoplasmic reticulum con- 
taining one or more nuclei, smaller translucent hyaline par- 
ticles, and the bacilli. Sometimes the smaller hyaline gran- 
ules and bacilli are found in the interstitial lymph channels 
in the fibrous structure. Through the increase of the infil- 
trate, more or less pressure atrophy of the glandular ele- 
ments results. The round cell becomes spindle-shaped, and 
finally forms fibrous tissue. Fatty or granular degeneration 
does not occur, and there are no evidences of breaking down. 

Symptoms. — The slow development and absence of sys- 






FuRUNCUI,OSIS. 211 

temic disturbances are characteristic. The disease usually 
commences at the margin of the nostrils and contiguous 
part of the upper lip, as small nodules, either discrete or 
confluent. They are firm, sharply defined, slightly elevated, 
hard and smooth to touch, traversed by dilated blood vessels, 
are hairless, and sometimes somewhat glossy. The tissue 
covering the masses may be natural in color or slightly 
darkened. With the exception of a slight tenderness on 
pressure, there is no pain. The tendency is to follow the 
mucous rather than the cutaneous surface, and the disease 
spreads by lateral infiltration, or coalescence. Occasionally 
it assumes the form of a general diffuse infiltration instead 
of forming nodules. The morbid process gradually ex- 
tends through the nasal mucous membrane, and may in- 
vade the pharyngeal, laryngeal, and even tracheal tissues, 
obstructing respiration and phonation. 

Diagnosis. — May be overlooked on account of its rarity, 
but by remembering the characteristic symptoms, it is com- 
paratively easy. 

Prognosis. — As far as a cure is concerned, it is unfavor- 
able, but there appears to be no effect upon the general 
health, excepting through mechanical interference with 
respiration when the larynx and trachea are involved. 

Treatment. — Purely empirical. 

Furuiiculosis. 

Synonyms. — Phlegmonous rhinitis ; boils. 

Furunculosis is applied to abscess formation of any part 
of the nose, but phlegmonous rhinitis is used only to indi- 
cate abscess of the nasal mucous membrane, which is sel- 
dom seen. 

Etiology. — As a rule follows an injury, and occurs most 
frequently on the septum near the nasal orifice. It may be 
single or multiple. A hair follicle may be the site of the in- 
flammation. In many persons furuncles occur fre- 



212 Nosk, Throat and Bar. 

quently, and involve the cartilage. Seen oftenest in the 
young or middle aged. Chronic constipation appears to be 
a factor in some cases. The infectious fevers also appear 
to favor their development. 

Pathology. — Same as anv abscess formation. 

Symptoms. — The swelling, throbbing, and sense of ten- 
sion is characteristic, as well as the appearance on in- 
spection. 

Treatment. — When pus has formed the abscess should 
be freely opened and the contents well washed out with some 
cleansing solution. The advisability of using a compress 
must depend upon the extent of the lesion. In some cases 
the pus is within the septum, separating the cartilage, and 
a sharp knife is required to puncture the cartilage. Inter- 
nally, the administration of calcium sulphide, or lime water 
should be persisted in for some time, as this has a tendency 
to prevent a recurrence. 



CHAPTER VIII. 

INFLAMMATORY DISEASES OF THE 
ANTERIOR NASAL CAVITIES. 



ULCERS OF THE ANTERIOR NASAL CAVITIES. 

These may be divided into non-infected and infected. 
The non-infected are divided into simple, and compound- 
malignant. 

The simple comprise eight classes : i, Catarrhal ; 2, Her- 
petic ; 3, Eczematous ; 4, Result of foreign bodies ; 5, Neuro- 
paralytic ; 6, Scorbutic ; 7, Diabetic ; 8, Varicose. 

Compound-Malignant. 

The infected are divided into: 1, Tubercular (lupoid). 
2, Syphilitic. 3, Leprous. 4, Glanders. 5, Diphtheritic. 6, 
In measles. 7, In rheumatism. 8, In scarlet fever. 9, In 
small-pox. 10, In typhoid fever. 11, In typhus fever. 
(Kyle). 

For convenience, the different forms of nasal mucous 
membrane ulceration will be considered collectively. 

A superficial necrosis extending through the basement 
membrane, whether involving the submucosa or not, is an 
ulcer. 

Whenever there is ulceration or fetid discharge, a care- 
ful inspection of the parts should always be made before 
cleansing, as this will aid in making a diagnosis. 

2r 3 



214 Nosk, Throat and Ear. 

Non-Infected Ulcers. 

Simple Uecers. 

Catarrhal. — In those cases where a profuse discharge 
is manifest, there are sometimes found ulcerated areas on 
prominent points near the nasal orifices. These points may 
be septal exostoses or contact surfaces between enlarged 
turbinates and the septum, or any location where secretion 
may be retained. The ulcerated areas are sensitive and 
painful, as a rule, and always cause the patient considerable 
annoyance. 

Treatment. — Careful cleansing of the ulcers with an al- 
kaline solution, followed by the salicylic acid wash. The 
application of stearate of zinc with salicylic acid will pro- 
tect and stimulate the ulcer. Aristol will also be found bene- 
ficial in many of these cases. Internally, the administration 
of potassium bichromate will nearly always cause a rapid 
improvement. 

Herpetic. — Herpes of the mucous membrane is some- 
times seen. The vesicles are in groups, each about the size 
of a millet seed or split pea. There is local irritation and 
rise of temperature, accelerated pulse and often considerable 
thirst. In a few days the vesicles dry, and thin scabs or 
crusts remain, which may unite, and usually without a sur- 
rounding inflammatory zone. 

Treatment. — Thorough cleansing of the area with an al- 
kaline solution, followed by the salicylic acid ointment. The 
bowels should be thoroughly evacuated. 

EczemaTous. — This form is oftenest found in young 
children who also have eczema on the upper lip and face. 
It sometimes follows the exanthemata, particularly measles. 
In adults it is occasionally found associated with eczema of 
other portions of the body. 

In children, an improper diet, or irritation of the lower 
bowel from ascarides or undigested material, may act as an 



Non-Infected Ulcers. 215 

exciting cause of this disease. The discharge seldom has an 
offensive odor. The amount of the secretion varies, but there 
is a formation of tough, firmly adherent crusts at different 
points. The itching which is often excessive, leads the pa- 
tient to pick the nose more or less continually, which in- 
creases the irritation, and usually prolongs the disease. 

In adults, the urine often shows an excess of urates. 
The individual is inclined to avoid exercise, and there is 
often a torpid state of both mind and body. 

Treatment. — An alkaline solution will best soften and 
cleanse. The application of the salicylic acid ointment 
should be made after all the crusts have been removed. In 
some cases beneficial results follow the application of a two 
per cent solution of silver nitrate. In children, the admin- 
istration of santonine often removes irritation of the bowels, 
even when worms are not present. If ascaris vermicularis 
are present, an infusion of quassia is a useful remedy. The 
diet should be nutritious, and avoidance of overfeeding is 
essential. The general health always needs attention. 

Ulcers Due to Foreign Bodies. — A foreign body in 
the nasal cavity may be the cause of an ulcer. The char- 
acteristics are usually the same as in the simple catarrhal 
type. The removal of the foreign body nearly always re- 
sults in a cure, but if not, the treatment already suggested 
should be employed. 

Neuroparalytic. — Paresis or paralysis of the fifth pair 
of nerves may cause ulceration of the nasal mucous mem- 
brane. Excoriations varying in size, dry, sluggish, and 
without a tendency to heal, are characteristic. Hemorrhage, 
as well as loss of smell on the affected side, is sometimes 
present. 

Treatment. — This should be directed to the cause of the 
nerve affection, restoring proper nerve stimulation. Locally, 
the use of cleansing solutions and stimulation of the ulcers 
are necessarv. 



2i6 • Nose, Throat and Ear. 

Scorbutic. — This is an extremely rare condition, but is 
sometimes seen in cases of scurvy when there has been irri- 
tation of the nasal mucous membrane. It may also occur as 
a part of a general facial scorbutic ulceration. The dis- 
charge is fetid and extremely offensive. The edges of the 
ulcers are thick, hard, and present a shiny appearance, while 
the surface is covered with clots of blood, and has a fungoid 
appearance. The ulcer usually spreads rapidly, and there 
is more or. less bleeding. 

Treatment. — The administration of lemon juice, and a 
vegetable diet seems to influence this disease more favorably 
than anything else. The ulcerative lesion should be kept 
clean with a solution of lemon juice or dilute hydrochloric 
acid, 10 drops to half an ounce of water. The fungoid 
masses should be removed with scissors and forceps, and a 
powder of salicylic acid one part, boric acid six parts, ap- 
plied to the surface. 

Diabetic — These ulcers are due to the general impaired 
condition of . the entire system, which often causes a low 
grade inflammation of the upper respiratory tract. As a 
rule the ulcers are near the nasal orifices, being the result of 
picking or rubbing the nose to relieve the intense itching 
usually present in diabetic cases. There appears to be a 
direct relationship between the ulcerative process and the 
amount of sugar in the urine. These ulcers do not present 
any especial characteristics, but in connection with diabetes 
should be treated as local manifestations of a systemic in- 
fection. 

Varicose. — The venous plexuses of the turbinal nasal 
region may become so engorged as to cause excessive dis- 
tension, even to the point of rupture and ulceration. The 
posterior border of the velum may also be affected. There 
is often a cyanotic condition of the mucous membrane in 
these case's. The ulcers are sluggish, forming slowly and 
healing equally as slowly. They present a bluish-red color, 






Infected Ulcers. 217 

are indolent, irregular in outline, shallow, and covered with 
a sanious, crusty discharge, and have a tendency to bleed 
freely. 

Treatment. — Locally the surface should be cleansed with 
the salicylic acid solution and distilled hamamelis. Inter- 
nally, the use of distilled hamamelis and collinsonia soon 
afford relief from the engorgement of the venous sinuses. 

Compound-Malignant Ulcers. 

An ulcerative process may occur when any malignant 
growth is present in the nose, but there is no especial dif- 
ference in the appearance from an ulceration in other parts 
of the body from the same cause, so the descriptions will be 
given under tumors. 

Infected Ulcers. 

Tubercular Ulcers (Lupoid). — In the nasal tissues, 
tuberculosis is uncommon. When it does occur, any of the 
structures may be the site of the lesion, but the septum ap- 
pears to be the preference. The simple tubercular ulcer is 
whitish gray, shallow, with irregular outline, and at times 
it is difficult to determine where the infection stops, and 
healthy membrane commences. ' In the early stages the 
miliary tubercles which have not broken down can often be 
seen near the periphery of the ulcer. There is a tendency 
to hemorrhage. The surface of the ulcer is often crusted 
with discolored mucus. 

Treatment. — When possible the infected area should be 
removed, either by the knife or by cautery. The trauma- 
tism is generally treated with 50 per cent lactic acid, and 
then covered with compound stearate of zinc with salicylic 
acid, mild. Aristpl may also be used. Iodoform is em- 
ployed, but on account of the odor is usually objected to by 
the patient. Internally, the treatment should be the same 
as employed for general tuberculosis. 



2i8 Nose, Throat and Ear. 

Syphilitic Ulcers. — In the nasal fossae we may have 
the initial sore, or any of the manifestations, even to necro- 
sis. Chancre of the nose is not often seen. It may present 
a granular appearance, or be hard and cartilaginous with an 
ulcerating surface. The symptoms are hemorrhage, steno- 
sis, and when located on the alse, deformity. 

The mucous patch in the nose is not liable to produce 
any subjective symptoms. The lesion is similar to the 
patches in the mouth. 

Superficial ulcer is infrequently seen. It is usually on 
the septum, but may be located on the turbinates, or floor 
of the nose. The edges of the ulcer are quite well defined, 
while the mucous membrane surrounding the lesion is nor- 
mal in appearance. There is a slight depression in the 
center of the ulcer. A thick, stringy, yellowish-gray muco- 
pus covers the surface of the ulcer. When this is removed, 
the surface presents a grayish pink color. The ulcerative 
area is but slightly sensitive to touch, but bleeds easily. 
There is but little tendency to extension. 

The deep ulcer with bony necrosis is the result of a 
gummy deposit, and as a rule does not appear until ten or 
fifteen years after the initial sore. The septum is most fre- 
quently affected, and the process is more amenable to treat- 
ment than when affecting the turbinates, where it assumes 
a more chronic type, with more extensive destruction of 
tissue through extension into the subjacent tissues. These 
ulcers seldom extend beyond the posterior nares. 

Treatment. — See nasal syphilis. 

Leprous Ulcers. — Generally caused by extension of the 
disease from the alse. When ulceration of the nodules oc* 
curs, the odor of the sanious, watery discharge is very of- 
fensive. Perforation of the triangular cartilage, and total 
destruction of the same, as well as of the alae, may occur 
in aggravated cases. The appearances have been described: 

Glanders. — In a few days after the onset of systemic 



Infected Ulcers. 219 

symptoms, there is a glairy, thick, fetid, deep yellow dis- 
charge, which is streaked with blood. The nodules, singly 
or in groups, are at first small, but rapidly increase in size. 
They are colorless in the early stages, then red, and finally 
yellowish, resembling pustules. Ulcerative tendencies are 
marked and with but slight disposition to heal. The ac- 
cessory sinuses may be affected. The diagnosis can be de- 
termined only by the systemic condition and history. 

Diphtheritic Ulcers. — Nasal diphtheria may be pri- 
mary, or secondary by extension. The peculiar grayish 
membrane, and acrid, irritating, brown ichorous discharge 
are characteristic of the nasal lesion. The ulceration is 
similar to that found elsewhere in this disease. 

Croupous, or Fibrinous Ulceration. — Chronic. — In 
persons where there is defective nutrition, a chronic mem- 
branous condition may affect the nasal tissues. The cause 
is obscure. Ulceration may occur, probably as the result of 
combined local infection and impaired nutrition. The treat- 
ment outlined under Fibrino-plastic Rhinitis is required. 

Uecers in Measees, Rheumatism, Scareet Fever, 
Smaee-pox, Typhoid Fever, and Typhus Fever. — The 
mucous tissue, and sometimes the bones and cartilages may 
be involved in ulceration, the result of the above named dis- 
eases. Perforation of the septum may occur, and oblitera- 
tion of the nostrils has been reported in small-pox. There 
are no characteristic peculiarities about the ulcers occurring 
in these diseases, but nasal manifestations should be noted. 
In typhoid fever, on account of the sub-normal state of the 
system, the ulcerative process may be so extensive, that the 
cartilage and bony structures may all be destroyed, caus- 
ing considerable deformity of the nose. 



CHAPTER IX. 
NASAL NEUROSES. 

Neuroses of Olfaction. — (i) Parosmia; (2) Hyper- 
osmia; (3) Anosmia. 

Reflex Nasal Neuroses. — (a) Respiratory Neuroses. 
(1) Sneezing; (2) Hydrorrhea; (3) Hyperesthetic rhinitis 
(Hay fever); (4) Cough; (5) Pharynx and mouth; (6) 
Larynx; (7) Asthma. 

(b) Reflexes Outside of the Respiratory Tract. — 
(1) Ear; (2) Eye; (3) Migraine, Congestive Headache, 
Neuralgia ; (4) Chorea, Epilepsy, Vertigo, and Aprosexia ; 
(5) Stomach; (6) Heart; (7) Sexual Organs. 

The general term neuroses includes changes in olfaction 
as well as reflex phenomena. 

Neuroses of Olfaction. — When the olfactory nerve 
terminals, the mucous membrane of the superior turbinates, 
the upper half of the middle turbinates, and upper three- 
fourths of the posterior portion of the septum are normal, 
allowing free circulation of air, the sense of smell is normal, 
provided the remainder of the olfactory tract is healthy. 

Any alteration of one or more of these factors may pro- 
duce loss of, or perversion of the sense of smell. 

Parosmia. — This is a perversion of the sense of smell, 
causing the perception of imaginary odors. Morbid condi- 
tions of the olfactory nerve or bulb, altered secretion, over- 
stimulation of the nerve terminals, or brain lesions, may be 
the causes of this condition. 

Sensory illusions of smell have been observed among in- 
sane people, and also in those affected with other nervous 
diseases. 

220 



Nasal Neuroses. 221 

Treatment. — This may be an early symptom of some 
brain lesion, and a careful examination should be made. 
Potassium iodide, potassium bichromate, pulsatilla, bryonia, 
or phosphorus, are most generally indicated.' 

Hyperosmia. — A hypersensitiveness to olfactory stimu- 
lation. Odors hardly perceptible to the ordinarily normal 
nose may be so marked as to be positively nauseating, and 
unpleasant odors may persist for several hours after the 
stimulus has been removed. Hypersensitiveness of the 
sense of smell, as well as exaggeration of all impressions, 
may result from the exhaustion of nerve force through ex- 
hausting or wasting diseases. This condition is also some- 
times found in hysteria, neurasthenia, or hypochondria. 

In women, hyperosmia may be present with sexual or 
uterine disturbances, especially during the menstrual period. 

Treatment. — The treatment must be directed to restor- 
ing the nervous system to as near normal as possible. In 
hyperosmia, ignatia and physostigma should be added to 
the list. 

Anosmia. — Impairment of the sense of smell may be 
partial or complete. When partial it is termed dysosphresia. 

Anosmia may be a congenital or an acquired defect. 
Changes in the upper nasal passages which prevent the free 
circulation of air may produce this condition. A "cold in 
the head" is a frequent cause of temporary loss of sense of 
smell. H. Zwaardsmaker divides anosmia into two general 
classes : First, as to obstruction, which prevents stimuli 
from reaching the olfactory region ; this may be in the an- 
terior cavities, preventing ingress to external odors, or by 
occlusion of the post nasal space or choanae, which prevents 
the odors accompanying the acts of eating or drinking from 
gaining access to the sensory region. 

Any malformations or morbid conditions of the nasal 
cavities, post-nasal growths, paralysis of the alaa nasi, or 



222 Nosk, Throat and Ear. 

absence of the external parts of the nose, may cause unilat- 
eral or bilateral loss of smell. 

Second, anosmia essentialis and anosmia intracranialis, 
depending on whether the nerve endings of the olfactory 
cells, the nerves themselves, or the central olfactory region 
of the brain is affected. 

Essential anosmia may be unilateral, bilateral, temporary 
or permanent. It may result primarily from direct irrita- 
tion of gases, strong, pungent, or disagreeable odors, or con- 
stantly inhaled tobacco smoke. Traumatism of the olfac- 
tory nerves, diseases or trauma of the ethmoid bone may 
produce anosmia. The application of cocaine or the supra- 
renal preparations have also caused temporary anosmia. 

Adenoids, polypi, increased or diminished nasal secre- 
tion, the extension of chronic inflammation from the nasal 
respiratory tract, ascending neuritis of the olfactory nerve, 
morphine, atropine, or mercurial poisoning may be causes 
of anosmia. 

Anosmia intracranialis may be caused primarily by an 
injury of the olfactory bulb or nerve tract, by tumors in 
close proximity, degenerative changes, congenital defects 
of the conducting nerves or receptive areas, and through 
senile degeneration. Secondary causes of anosmia may be 
hemorrhage, abscess, tumors, necrotic or atrophic intra- 
cranial conditions. 

Prognosis. — This will depend very much upon the cause. 
The length of time anosmia has been present does not have 
much influence, as cures have been reported where the de- 
fect had existed for over thirty years. 

Treatment. — When not due to some central lesion, im- 
provement can sometimes be obtained by both local and 
internal treatment. Vibratory massage or the galvanic cur- 
rent has given good results in some cases, where stimula- 
tion of the olfactory region was required. Internally, nux, 
phosphorus, ignatia, or hyoscyamus may be needed. 



Reflex Nasai, Nfurosks. 223 

Reflex Nasal Neuroses. 

This term is applied to symptoms originating in nasal 
excitability or nervous instability. The term reflex, al- 
though generally applied, is hardly appropriate, as physio- 
logically it means the reaction of a nerve center to an im- 
pulse transmitted to it by a sensory nerve, the response be- 
ing in the form of activity of some centrifugal nerve. The 
terms sensory, motor, trophic, and vasomotor neuroses of 
peripheral origin are better. Two general divisions are 
most convenient ; neuroses of the respiratory tract, and 
neuroses affecting other portions of the body. 

Respiratory Neuroses. 

This includes the reflex phenomena' occurring in the 
nose, nasopharynx, pharynx, mouth, larynx, and bronchi. 

Sneezing. — Paroxysmal sneezing often occurs where no 
alteration of the nasal tissues can be discovered. It may be 
the result of an exceedingly irritable condition of the mem- 
branes, with a corresponding irritability of the vasomotor 
centers depending upon a lowered vitality. In the majority 
of cases, however, there is unilateral or bilateral vascular 
occlusion with excessive secretion. This condition varies 
with the state of the nervous system, and depends upon 
the direct cause, as drafts, irritating fumes, dust, etc. In 
some instances, an exciting lesion is found in the nasal 
fossae, as polypi, septal spurs, or an excessive chronic dis- 
tention of the cavernous tissue. 

Treatment. — When possible to locate the exciting cause, 
its removal will suffice. When due to overdistention of the 
cavernous tissue, contraction by means of submucus punc- 
ture, the galvano cautery, or similar measures should be 
employed. When no exciting cause can be found, the gen- 
eral health should be improved. 



224 Nosie, Throat and Ear. 

Hyperesthetic Rhinitis. 

Synonyms. — Autumnal catarrh; Catarrhus aestivus; 
Coryza vasomotoria periodica ; Hay asthma ; Hay fever ; 
Idiosyncratic coryza ; June cold ; Peach cold ; Periodical 
hyperesthetic rhinitis ; Pollen catarrh ; Pruritic rhinitis ; 
Rag-weed fever ; Rhinitis hyperesthetica ; Rose catarrh ; 
Rose cold ; Rose fever ; Summer catarrh. 

This disease, if it is a disease, is a periodical inflam- 
matory state of the nasal tissues, usually with the lapse of a 
year between the attacks. It is most prevalent during the 
warmer seasons of the year, although well marked cases 
occur during the winter months. Seldom seen before the 
age of ten years, and the primary attack is infrequent after 
twenty-five. After forty the condition is seldom seen. 

Various theories have been advanced regarding the 
cause of this condition. The theory of a local irritant, due 
either to some substance in the atmosphere, as pollen, or to 
a local manifestation from some systemic wrong, as uric 
acid, — is most generally accepted. The most plausible 
theories, however, are that it is either a disease of the nasal 
tissues, giving rise to various reflexes, or that it is a neu- 
rosis. The condition is found most frequently among per- 
sons having a highly developed nervous organization. How 
ijnuch of a factor the psychological condition plays is a 
question. 

Etiology. — Predisposing Causes. — Either neurosthenia 
or neurasthenia may be predisposing factors. There may 
be a hereditary tendency, as found in neurotic families, or it 
may be the sequence of a prolonged nervous strain. It is a 
well-known fact that the condition is more prevalent among 
the highly educated than the illiterate ; among those whose 
vocation requires mental effort, rather than physical, and 
also among urban rather than country people. 

It is evident that no one cause can be ascribed as an 
etiological factor, but various causes may, and do, produce 



Hyperesthetic Rhinitis. 225 

the same general line of symptoms, which are grouped as 
hay fever or hyperesthetic rhinitis. Sensitive areas of the 
nasal mucous tissue, or malformations of the nasal fossae 
may be ascribed as factors in some cases, although such con- 
ditions are probably more sensitive to an irritant. Kyle be- 
lieves that in many cases the cause of the local irritant is 
due to some chemical change in the secretion of the mucous 
glands. The conjunctiva, stomach, and frequently the blad- 
der are affected in this disease, and the uric acid theory 
does not explain all the cases. As the arterial supply of the 
nasal and nasopharyngeal mucous membrane comes mostly 
through the bony structures, which also support the mem- 
brane, it is easy to see why these regions should be more 
susceptible to congestion, infiltration, and deposit, than 
where there is a muscular foundation. 

Males are oftener affected than females, and usually 
prior to the age of forty. Occasional cases are found when 
the initial attack is subsequent to this age, and one case has 
been reported in a child of two years. The disease is most 
prevalent in the United States and England. High alti- 
tudes seem to be practically free from the condition, al- 
though this is not an invariable rule. Americans and Eng- 
lish are the races most affected. 

Exciting Causes. — Bla'ckley has demonstrated that pollen 
is the exciting cause in the majority of cases. Some indi- 
viduals are susceptible to ammoniacal fumes, while others 
may be influenced by apparently innocuous substances. 

Pathology. — During an attack, all the evidences of a 
catarrhal inflammation are present, but there are no char- 
acteristic structural changes. Hypersensitive areas are 
present during the attack, usually located at the extremities 
of the inferior turbinates, and at a corresponding point on 
the posterior portion of the septum. On the anterior part 
of the septum, or nasal wall, within the angle defining the 
vestibule, there is also, often, a sensitive area. The mid- 
15 



226 Nose, Throat and Ear. 

surface of the middle turbinate may also occasionally have 
an area of hypersensitiveness. These areas are necessary 
for the attack, as mechanical irritation of these surfaces 
causes an acute manifestation of the condition. 

Symptoms. — These vary in different individuals, and 
even in the same person during different attacks. The usual 
premonitory symptoms can be summed up in the words 
"spring fever," the drowsiness, lassitude, and weariness 
being extreme. Sneezing soon follows, and the paroxysms 




FiG. 62. Nerve supply of nasal mucosa, a. Sphenopalatine ganglion; 

b. posterior area; c. middle area; d. anterior area; 

e. olfactory bulb. 

are sometimes of long duration. Itching and burning of the 
nose, eyes, and roof of the mouth are part, or all, present. 
Lacrimation and a thin ichorous discharge from the nose 
soon follows. The burning sensation of the eyes is often 
marked, and the conjunctiva becomes congested, the flow of 
tears becoming more marked. Frequently nasal respira- 
tion is impossible owing to the congestion of the turbinates. 
Headache follows, and as a result of mouth breathing, the 
pharyngeal mucous membrane becomes dry and irritated, 
and the larynx irritable. Cough soon makes its appearance, 



Hyperesthetic Rhinitis. 227 

and the asthmatic conditions are so pronounced in some 
cases that bronchial catarrh with asthma is the diagnosis. 
The asthmatic symptoms become more marked with re- 
peated attacks. 

Diagnosis. — This is not difficult, as acute nasal catarrh 
is about the only affliction that could be mistaken for this 
disease. 

Treatment. — The main reliance has been on local treat- 
ment, and as a result has not been very successful. Internal 
treatment for the relief and diminution of the severity of 
the attacks must be borne in mind. 

The local application of cocaine has held for a number 
of years, but the effects are so transient that it keeps the pa- 
tient busy alternating the cocaine and handkerchief. I have 
used the unguent-salicylic acid in those cases having the 
full turbinal tissues, and a few applications seemed to give 
very marked relief. The engorged conditions passed off, not 
as rapidly ~s under cocaine, but more permanently. 

In the early stages, especially with anemic, delicate per- 
sons, the arsenic iodide, -1-100 gr., given three or four times 
a day, will give relief and mitigate the attack as a rule. 
Euphrasia has been recommended, when the lacrimation 
is profuse and a burning sensation was present. Gelsemium 
seems to find a place where there is fullness in the frontal 
region, dryness of the nasal fossae, and mild nasal obstruc- 
tion. Naphthaline has been much extolled. The indications 
given are marked asthmatic symptoms, the discharges from 
the nose and eyes excoriating. The 1-100 gr. is given in- 
ternally, and y=> per cent solution may be used locally. I 
have had no experience with this drug. 

Taking the theory that uric acid is the prime cause, the 
treatment resolves itself into anti-uric acid treatment. The 
administration of dilute phosphoric acid in these cases has 
been tried, and favorable results reported. I have had no 
experience with this form of treatment, but would rely more 



228 Nose, Throat and Ear. 

on such remedies as I have found efficacious in similar forms 
of rhinitis, sticta when the secretion is scanty, but a desire 
to blow the nose, potassium bichromate with thick tenacious 
discharge, distilled hamamelis with thin, watery, non-ex- 
coriating discharge, liquor potassii arsenitis with thin, 
watery, excoriating discharge. In fact, whatever is the in- 
dicated remedy should be employed. 

Cough. — Nasal cough may result from a simple coryza, 
chronic or hyperplastic rhinitis, septal irregularities, polypi, 
hypertrophic conditions of the nasal structures or from vaso- 
motor changes. Mackenzie, as the result of experiments, 
describes a "well defined sensitive area situated near the 
posterior extremity of the inferior turbinated bone and con- 
tiguous portion of the septum. " When this region is irri- 
tated, through any cause, reflex cough results. A careful 
investigation will often reveal this locality as the origin of 
a cough for which no other causecan be found. 

Pharynx and Mouth. — Nasal disease has been cred- 
ited with producing in this region, hyperesthesia, parasthesia 
or the sensation of a foreign body, neuralgia, palatal paresis, 
dysphagia, hiccough, and salivation. 

Larynx. — Aphonia has been reported cured by nasal 
medication. There is no question but that the presence of 
abnormal nasal or nasopharyngeal conditions may produce 
laryngeal spasm or spasmodic croup. 

Asthma. — Intranasal irritation is in some cases the 
cause of asthma, hence after the elimination of other causes, 
the nose should be carefully examined. In cases of nasal 
asthma, the rales are dry just preceding and following the 
attack. 

Treatment. — This resolves itself into restoring as nearly 
as possible the normal condition of the nose as well as of 
the general system. 



Reflexes Outside the Respiratory Tract. 229 

Reflexes Outside of the Respiratory Tract. 

Ear. — Reflex conditions ascribed to nasal irritation are 
sometimes found in the ear. A persistent cough may result 
from reflex irritation produced by impacted cerumen, for- 
eign bodies in the external auditory canal, or, as I have 
found in two cases, moist eczema of the canal when the exu- 
dation was allowed to remain for some time. In one case 
under observation, severe asthmatic attacks were cured by 
the removal of a ceruminous mass from the right ear. Ear- 
ache, tinnitus aurium, and other aural manifestations have 
been credited as reflex from nasal diseases. 

Eye. — Lacrimation is of frequent occurrence when ap- 
plications are made to the nasal tissues, or when nasal irri- 
tation is due to nasal lesions. Among the numerous reflexes 
may be mentioned asthenopia, retinal hyperesthesia, photo- 
phobia, scintillating scotomata, phlyctenular conjunctivitis, 
blepharitis, edema, glaucoma, and pain in the eyeballs. 
Operative measures on the nasal tissues may also produce 
some of the sr.me conditions. 

Migraine, Congestive Headache, Neuralgia (Supra- 
orbital, Tic Douloureux). — A cure or relief has followed 
treatment of the nasal fossae in many cases of migraine or 
sick headache, the so-called congestive headaches, and neu- 
ralgia of the various branches of the trigeminus nerve. In 
the headaches frequently seen at the age of puberty, the 
nasal mucous membrane seems to be peculiarly irritable. 
Neuralgia may be a reflex phenomenon of adenoids, lesions 
of the middle and posterior parts of the inferior turbinates, 
septal spins, and synechias. In one especially marked case 
of supraorbital neuralgia, I found a large polypus, the re- 
moval of which gave immediate relief. 

Chorea, Epilepsy, Vertigo, Aprosexia. — In chorea 
and epilepsy, whether the reported cures following the cor- 
rection of nasal lesions and removal of adenoids,, were due 



2$d Nose, Throat and Har. 

to the removal of these obstructions, or on account of the 
improvement of the general health which usually rapidly 
follows unobstructed breathing, is a question. 

Vertigo. — In this condition there is also an element of 
doubt, as the attacks may have been aural in type, through 
the extension of the nasal disease, producing morbid changes 
in the Eustachian tube or middle ear. 

Aprosexia (inability to fix the mind on any subject.) — 
This is a nasal reflex which is supposed to depend upon 
the communication between the nose and brain. 

Stomach. — Gastric disturbances have been supposed to 
be reflex from nasal lesions, but they are more likely to be 
the result of extension through continuity of tissue, or the 
ingestion of the nasal secretions. The swallowing of air, 
which is not uncommon when the nose is occluded, may 
also be a cause of nausea, etc. 

Heart. — Cardiac disturbances have been credited to 
nasal lesions. Some cases of exophthalmic goitre have been 
reported cured by treatment of the nose. 

Erythema, urticaria and acne oe the nose and face 
have been referred to intranasal diseases. 

Sexual Organs. — Overindulgence of the physiological 
sexual function, the changes at the time of puberty, preg- 
nancy, menopause, and menstrual derangements, or chronic 
diseases of the uterus and ovaries, may produce reflex nasal 
symptoms, as sneezing, dyspnea, or epistaxis. 

Treatment. — In all of these cases, both local and consti- 
tutional measures should be employed. 

Local. — Polypi, adenoids, or other growths should be re- 
moved by surgical means, deflections of the septum cor- 
rected, septal spurs removed, and enlarged turbinates, or 
redundancy of tissue, reduced by such means as seem best 
fitted to the case. But in all these procedures care must be 
exercised that an aggravation of the condition does not fol- 
low. Some disturbance is to be expected for a few days fol- 



Reflexes Outside the Respiratory Tract. 231 

lowing mechanical interference, but it. should soon dis- 
appear. 

Constitutional. — A careful examination of each case 
must be made, and any systemic wrong treated from a ra- 
tional standpoint, endeavoring to restore both the physical 
and the nervous systems to their normal conditions. 



CHAPTER X. 

NON-INFLAMMATORY DISEASES OF 
THE ANTERIOR NASAL CAVITIES. 



Epistaxis. 

Varieties. — i, traumatic; 2, local nasal lesions; 3, sys- 
temic ; 4, vicarious. 

Synonyms. — Nose-bleed ; hemorrhagia narium ; rhinor- 
rhagia. 

Etiology. — The statement is made that epistaxis may be 
a symptom, a disease, or a physiological process. It is 
most prevalent in males, and occurs more frequently be- 
tween the ages of two years and puberty. At no period of 
life, however, is there an immunity from this condition. 

The four divisions given are the most convenient for 
classification. 

(1) Traumatic. — Blows upon the nose, occurring in 
various ways, are probably the most frequent cause. Abra- 
sions of the mucous membrane may be the result either of 
accident or operative measures, or the careless handling of 
instruments in making an examination or local applications, 
the introduction of foreign bodies, so frequent among chil- 
dren ; picking the nose, a not uncommon habit even among 
adults; or the occupation, in which one is exposed to 
the inhalation of irritating dust or acrid fumes. In this 
class come steel grinders, stone cutters, chemical and med- 
ical drug workers. 

(2) Local Nasal Lesions. — The hyperemia present in 
the different nasal diseases, predisposes to hemorrhage. In- 

232 



Epistaxis. 233 

creased heart action through severe manual exercise, as 
well as in the physical, changes occurring at puberty, pro- 
duces hyperemia of the nasal tissue, which often results in 
epistaxis. In these conditions the hemorrhage may be re- 
garded as a natural means of relief. Sexual abuse has been 
ascribed as a factor by some, but other abnormalities may 
really be the exciting cause. In ulcerative lesions a bloody 
discharge is frequent, especially in malignant growths. For- 
eign bodies, when present for some time, may act as ex- 
citing factors in causing hemorrhage. Polypi and adenoid 
growths are often causes of bloody or blood-streaked dis- 
charges. In hay fever the nasal secretions are often tinged 
with blood. Malformations of the septum may also be a 
cause. In simple, chronic, or atrophic rhinitis, hemorrhage 
often follows slight mechanical interference. 

(3) Systemic. — This division comprises a long list, and 
the nasal hemorrhage may be of little consequence, or it 
may be a serious matter. The hemorrhagic diathesis, hemo- 
philia or bleeder, is probably the most intractable. Often 
the first intimation of this condition is a profuse, persistent 
nasal hemorrhage which may come on without any appre- 
ciable cause, by some agency so slight as to be overlooked. 

Epistaxis may appear at the onset of typhoid fever, and 
at any time during the eruptive fevers, and also may occur 
in diphtheria, pneumonia, relapsing fever, influenza, gout, 
scurvy, purpura, the anemias, bronchitis, emphysema, spe- 
cific inflammations, as syphilis, tuberculosis, and leprosy. 

Cardiac lesions may also cause congestion of the- nasal 
mucous membrane, resulting in hemorrhage. In arterio- 
sclerosis hemorrhage seldom occurs, although ecchymotic 
spots are not infrequent in the post-nasal space. In cirrhosis 
and acute yellow atrophy of the liver, or in pressure caused 
by neighboring tumors or enlarged organs, there may be. 
some nasal hemorrhage. Albuminuria, bronchocele, or 
other tumors of the neck, which cause pressure, retarding 



234 Nose, Throat and Kar. 

the return flow of blood, ill-fitting or tight neckwear may be 
exciting causes. Plethoric persons are often troubled with 
nasal hemorrhage. Chronic alcoholism and the atheroma 
of the aged are predisposing factors. A slight hemorrhage 
may precede or accompany apoplexy. 

Congestion of the cerebral vessels during continued or 
severe mental effort, is occasionally relieved by a nasal 
hemorrhage. Atmospheric conditions are in some cases a 
factor, through the disturbance of the intra- and extra-vas- 
cular pressure. This accounts for the frequency of epis- 
taxis in making rapid ascents to higher altitudes, or among 
workers in deep mines or in caissons, who are affected 'on 
reaching the normal atmospheric pressure. The toxic doses 
of some drugs occasionally produce epistaxis, as phosphorus, 
chloramid, and the compounds of the salicyl group. 

(4) Vicarious. — Vicarious menstruation is usually from 
the nasal tissues. Epistaxis may occur when there is a sud- 
den cessation of the flow of blood from hemorrhoids. A 
severe sneeze, cough, or energetic blowing of the nose may 
also start a hemorrhage. 

Pathology. — On account of the anatomical construction 
in this region, there is neither muscular structure in which 
the tissues are imbedded, nor muscular contraction to assist 
in closing a wound, or retraction of the severed ends of 
blood vessels. Hemorrhage may be from any part of the 
nasal membrane. Certain areas are more likely to be the 
site, especially at a point in the anterior inferior part of 
the septum, called the locus Kieselbachii, where the vascular 
plexus is the most intricate. 

On inspection the membrane may be red and swollen ; it 
may present varicosities, erosions, or a sharp cut. In some 
cases the margins of a perforation of the septum, or the 
edges of a ruptured cyst may be the site. The hemorrhage 
may be a slow, steady, capillary oozing, a more rapid flow, 
or a rapid pulsating arterial flow. Usually the hemorrhage 
ceases spontaneously, as a rule, through the formation of 



Epistaxis. 235 

thrombi. After a copious hemorrhage the membrane is 
often pale and anemic, but soon regains its normal appear- 
ance. In plethora, severe renal and cardiac conditions, epis- 
taxis appears to be nature's method of relief, and in these 
cases it does not constitute a pathological epistaxis. 

Symptoms. — The prominent symptom is the escape of 
blood through the anterior nares ; if in the posterior part, 
or the patient is in the recumbent position, the blood passes 
through the choanse into the pharynx, and if swallowed or 
it enters the bronchial and pulmonary tracts the appearance 
when ejected may simulate hematemesis or hemoptysis. 

The quantity of blood lost varies from an amount so 
slight as to scarcely tinge the nasal secretions, to a profuse, 
persistent flow. The attacks may be infrequent, or may 
occur daily, and may last from a few minutes to several 
hours. As a rule, the blood coagulates readily, excepting in 
hemophilia. Often there are no preliminary symptoms, the 
first intimation being a bubbling of the inspired air through 
the blood in the respiratory tract, the discoloration of the 
handkerchief in trying to relieve the sensation of fullness, 
or the blood dropping from the nose. In other cases there 
may be, prior to the attack, congestive headache, sensation 
of fullness of the head, tinnitus aurium, vertigo, or visual 
disturbances. 

The sequelae vary considerably, depending upon the 
amount of the hemorrhage. In cases of plethora, or con- 
gestive renal, hepatic, or cardiac states, there is usually a 
sense of general relief. In many cases where the amount 
of blood lost is inconsiderable, little or no after effects are 
noticed. When the amount is considerable, headache, or the 
symptoms of exsanguination and syncope may soon appear. 
The hemorrhage may be unilateral or bilateral. As a rule, 
when depending upon local affections or a traumatism, it 
is from one side. Systemic or vicarious epistaxis is usually 
from both sides. The site of the hemorrhage can usually 



236 Nose, Throat and Ear. 

be located by anterior or posterior rhinoscopy. It is. claimed 
by some that a brownish stain reveals the site, during the 
intervals between periodical attacks. 

Diagnosis. — The diagnosis is usually easy, but both an- 
terior and posterior rhinoscopy may be necessary for a posi- 
tive diagnosis. The hemorrhages from local lesions are 
usually unilateral, but those from the stomach, pharynx, 
lungs, tongue, or fractures of the base of the skull, when 
the exit is through the nose, are generally bilateral, unless 
there is occlusion of one side. In the latter condition, there 
is usually a clinical history which will establish the diag- 
nosis. A hemorrhage from the posterior and inferior part 
of the septum may be deceptive. Hemorrhage from the 
accessory sinuses are often difficult to locate, but if the 
bleeding is at or near the openings of the sinuses, care 
should be taken in making the diagnosis. 

Prognosis. — Generally favorable, unless the hemorrhage 
is the result of malignant growths in the nose. When due 
to systemic lesions the prognosis will depend upon the char- 
acter of the disease. In hemophilia or in chronic heart dis- 
ease the outlook is unfavorable. 

Complications. — Syncope sometimes occurs, not only on 
account of the loss of blood, but also through psycholog- 
ical effects produced by the sight of blood. 

Treatment.— When dependent upon systemic diseases, 
the treatment must be directed to the exciting cause. If due 
to foreign bodies, their removal is necessary. In the ma- 
jority of cases no treatment is required. When the hemor- 
rhage is moderately severe, pressure on the alse, if from this 
portion, or on the upper lip so that the superior coronary 
artery is compressed, when from the septum, may control 
the bleeding. The use of mineral astringents, as a rule, 
should be avoided, as the resulting mass is often difficult of 
removal, and when removed is frequently followed by an- 
other hemorrhage. Tannic acid in powder, or a 10 per cent 
solution is sometimes effective. The use of cocaine, while 






Epistaxis. 237 

it may check the hemorrhage, is dangerous on account of 
the danger of absorption. The use of the suprarenal prod- 
ucts, while often temporarily useful, is not advisable, as 
secondary hemorrhage is not unlikely. 

The recumbent position, with the arms extended above 
the head, sometimes suffices. The use of cauterants, as a 
rule, should be avoided. In some cases the plugging of 
the nares by the use of Bellocq's canula, or the" nasal gauze 
packer, may be necessary. The cotton or gauze should be 
covered with some oily substance in order to prevent shrink- 
ing, and also to facilitate removal. When cotton tampons 
are used, a thread should be fastened around each one, so 
they may be readily removed. The use of small rubber 
bags introduced into the nares, then inflated with air, or 
filled with water, has also been recommended. Kyle re- 
ports a case in which the posterior nares was occluded with 
pledgets of cotton, then the anterior nares plugged with 
the same material, leaving the intervening space to be filled 
with blood, the pressure eventually causing the hemorrhage 
to cease. The objection to this method is the possibility of 
the blood entering the maxillary sinus and producing in- 
flammatory action. When the nasal cavities have been tam- 
poned, the tampons should not be allowed to remain over 
forty-eight hours, and usually a shorter time is sufficient. 
If left too long, either pyemia or the pressure of the pack- 
ing may devitalize the tissues. A careful cleansing of the 
nasal cavities should follow the removal of the tampons, and 
the patient should be cautioned against over-exertion for 
several days. 

Internally, the use of ergot when the hemorrhage is 
arterial in character ; hamamelis in hemorrhoidal cases, or 
"where there is simply a venous oozing. Carbo veg. is also 
indicated in the oozing form. Belladonna in some cases. 
Cactus in functional heart disease. Glonoin in organic car- 
diac lesions. In cases of anemia, with lowered arterial 
pressure, nux, or veratrum may be indicated. 



CHAPTER XL 

FOREIGN BODIES IN THE AN- 
TERIOR NASAL CAVITIES. 

(i) Inanimate; (a) Rhinoeiths, (b) Miscella- 
neous. (2) Animate, (a) Parasites. 

Inanimate. 

Rhinoeiths. 

Synonyms. — Nasal calculi ; Nasal concretions. 

A rhinolith is a foreign body in the nasal cavity formed 
by the deposit of mineral salts ; in nearly every case there 
is a nucleus of some kind forming a nidus. 

Etiology. — These formations are usually the result of 
either a modification of the nasal secretions, or some condi- 
tion causing its retention. Females appear most liable to 
this condition, and the gouty diathesis has found favor with 
some as a factor. They are seldom found in children. 

Location. — Usually in the inferior meatus, but may occur 
in any portion of the nasal cavity. , 

These formations are single, as a rule, although occa- 
sionally two are found joined together. The shape varies, 
as also the weight, from a grain or two, to a quite large 
mass, 720 grains being reported in one case. The surface 
may be comparatively smooth, or rough. The color varies 
from a dirty white to almost black. They may be compact 
or friable. In some cases the outer portion is hard while 
the center is soft or crumbling. The composition is usually 
the carbonates and phosphates of calcium and magnesium, 
with traces of chloride and carbonate of sodium, and or- 

238 



Inanimate. 239 

gaiiic material. The typical structure of a calculus is 
usually shown and with some sort of a nucleus. 

Symptoms. — Usually none, until the rhinolith is of suffi- 
cient size to cause the usual line of symptoms caused by a 
foreign body. 

Diagnosis. — An inspection of the nasal cavity after thor- 
ough cleansing, the use of a probe, and the history, will 
suffice. 

Prognosis. — The same as any foreign body in this region. 

Treatment. — When not encysted, the removal is usually 
easily accomplished in the same manner as any foreign body. 
When encysted, it should be freed from its surroundings 
and removed. When of considerable size, and soft enough 
to be crushed, the removal is easy. The subsequent treat- 
ment is cleansing the nasal cavity two or three times a day 
with an alkaline wash, until there is no longer any irritation. 

Miscellaneous. 

The inanimate objects which may be found in the nasal 
cavities are limited only by the inability of entrance to the 
spaces. 

Etiology. — There are three methods of entrance. Direct 
insertion anteriorly by the patient, which is more often ob- 
served in children, the mentally unbalanced and malingerers. 
Also through the choanse, the result of vomiting, or chok- 
ing during the act of swallowing, when the material may 
be forced behind the soft palate. In paralysis of the faucial 
tissues, this is often an annoying feature during the act of 
deglutition. Penetration of the nasal structures has in a 
few instances been observed, and comprises the third 
method. 

Pathology. — This necessarily varies according to the 
character of the foreign substance. It may be so small, and 
so located, that no attention is given to its presence. The 
opposite extreme is also found, and variations between the 



240 Nosk, Throat and Ear. 

two are quite frequent. In some cases an acute inflamma- 
tion is caused almost at once, or may appear only after the 
lapse of considerable time. The membrane becomes swollen, 
the submucosa infiltrated as in any inflammatory process, 
and there is increased activity of the glandular elements in 
the immediate vicinity of the offending object. As the 
swelling continues there is increased pressure, and in such 
substances as absorb moisture with consequent increase of 
size, the nutrition to the affected area is destroyed, and 
necrotic changes occur in the epithelium. Through this 
change infection results, and irregular ulcerations are 
formed. In cases where the neighboring vessels can supply 
sufficient nutriment to cause budding, granulation tissue 
may form, more or less embedding the foreign body. When 
the pressure. is considerable and is continued for some time, 
the necrosis will extend to the deeper structures, and there 
may result a perforation of the septum, the nasal floor, or 
even the lateral wall. It is not often, however, that such 
results occur, as medical assistance is usually sought before 
the ulcerative stage is reached. As a result of the inflam- 
matory action, there is a retention of secretion through nasal 
obstruction, and decomposition rapidly following, the odor 
becomes intolerable. The retention of this putrefactive 
material maintains or increases the inflammatory process. 
Epistaxis is often present. 

Symptoms. — These vary according to the size, charac- 
ter, and location of the body. In an ordinarily severe case 
the membrane is swollen, reddened, and painful ; there is an 
increased discharge, glairy at first, then mucoid, and later 
purulent and frequently offensive. Unless there is perfora- 
tion of the septum, the discharge is unilateral, and may be 
streaked with blood. When acrid, there is excoriation of 
the nostril and upper lip. Respiration on the affected side 
is impaired and a nasal twang imparted to the voice. The 
ala is often reddened and swollen. Neuralgic pain in the 
nose, cheek, or frontal region may be present, and the eye 



Animate. 241 

or ear be implicated. Paroxysms of sneezing, vertigo, 
nausea, and vomiting may result. 

Inspection of the nasal cavity will usually reveal the for- 
eign body, although in some cases a thorough cleansing of 
the cavity may first be necessary. When the foreign body 
has been pushed far back in the meatus by unsuccessful at- 
tempts at removal, a probe may be necessary to definitely 
locate the object. As a rule the location is in the anterior 
portion, between the inferior turbinate and the septum. 

Diagnosis. — Not difficult as a rule. 

Prognosis. — Good, as the removal of the foreign body is 
usually followed by a rapid amelioration of the annoying 
symptoms. 

Treatment. — But few objects can successfully be re- 
moved by the use of forceps, which will only push back still 
further into the nasal fossa an object that is smooth and 
hard. Quier's foreign body extractor is useful in many 
cases, while a probe bent to form a hook may often be all 
that is required. An aneurism needle has frequently been 
a useful instrument in these cases, and the Gross curette, 
especially when the object is a bean or something which 
can be penetrated by the sharp point, may remove the body. 
If a shoe button, and the eye is forward, it can be grasped 
with forceps. If an organic body and it has swollen, it 
may be necessary to break or crush it before it can be re- 
moved. The post nasal syringe has been successfully used, 
and the tip of a Politzer air bag placed in the free nostril, so 
as to close it, then compressing the bulb forcibly, may expel 
the body. After the removal of a foreign body the nose 
may be cleansed two or three times a day with some sooth- 
ing wash. 

Animate. 

In some parts of the country, reports are not infrequent 
of the larvae of flies being found in the nasal cavities. In 
northern latitudes this seldom happens. The invasion of the 
16 



242 Nose, Throat and Ear. 

nasal cavities by any animate object causes more or less 
pain, as well as increased secretion. When due to larvae it is 
the result of ova deposited in the nasal cavity. These hatch 
and the maggots develop. 

Course. — If allowed to remain, the mucous membranes 
and underlying tissues are soon destroyed, and bony necrosis 
follows. Suppuration is extensive, and the larvae may bur- 
row through the nasal walls, or into the accessory sinuses, 
and even into the cranial cavity. Meningeal inflammation 
frequently occurs where the bony structures are affected, 
resulting fatally. 

Symptoms. — The symptoms are very pronounced. The 
discomfort and pain rapidly increase. The pain may be 
referred to any portion of the head, but the frontal region 
is most affected, the pain being persistent. The secretion 
soon becomes purulent, and frequent hemorrhage is present. 
Edema of the face often occurs. Severe septic poisoning 
is shown by the systemic disturbance. 

Diagnosis. — This is positively made by the discovery of 
the larvae in the discharges, or in the nasal cavities. 

Prognosis. — This depends upon the progress the de- 
structive process has made as well as upon the condition of 
the general health. 

Treatment. — When possible to get any air through the 
nasal cavities, the vapor of chloroform or gasoline will kill 
the larvae. The procedure of injecting chloroform and 
water, equal parts, into the nasal cavities is not to be recom- 
mended. The vapor should be forcibly blown into the cavi- 
ties, either by means of a Devilbiss powder blower, or some 
instrument where sufficient pressure can be used to get 
penetration of the vapor. The larvae can then usually be 
easily removed by syringing, but may have to be picked out 
with a forceps. A cleansing solution should be used after 
the removal of the larvae, and following this, the salicylic 
acid wash. If the Accessory sinuses are invaded, operative 
measures are imperative. 



CHAPTER XII. 

NEOPLASMS OF THE RESPIRA- 
TORY TRACT. 



DIVISIONS. 

Non-Malignant. 

Origin. — Blastodermic layer — hypoblastic, epiblastic. 
Epithelial-tissue type — adult variety (typical, benign), (i) 
Papilloma. (2) Adenoma. 

Origin. — Blastodermic layer — mesoblastic. Connective- 
tissue type — adult variety (typical, benign). (1) Angioma. 
(2) Chondroma (enchondroma). (3) Exostosis. (4) 
Fibroma. (5) Lipoma. (6) Osteoma, (a) Eburnated; (b) 
Cancellated. (7) Myxoma (polyp), (a) Myxofibroma; 
(b) Mucocele; (c) Cystic. 

Malignant. 

Origin. — Blastodermic layer — hypoblastic, epiblastic. 
Epithelial-tissue type — embryonic variety (atypical, malig- 
nant). (1) Carcinoma, (a) Epithelioma. I, Squamous- 
celled. 2, Cylindrical-celled. 3, Tubulated, (b) Glandular. 
1, Scirrhous. 2, Encephaloid. 

Origin. — Blastodermic layer — mesoblastic. Connective- 
tissue type — embryonic variety (atypical, malignant). (1) 
Sarcoma, (a) Round-celled, small and large, (b) Spindle- 
celled, small and large, (c) Mixed-celled, (d) Giant or 
myeloid, (e) Alveolar. 

243 



244 Nose, Throat and Bar. 

Mixed Tumors. 

I, Adenocarcinoma. 2, Myxocarcinoma. 3, Myxosar- 
coma. 4. Myxofibroma. 5, Teratoma. 

Cysts. 

1, Simple or Retention-cysts. 2, Cystoma. 3, Dermoid 
cysts. 

All neoplasms of the upper air passages will be consid- 
ered under this chapter heading. 

Papilloma. 

Nares. — When the growth is situated at the junction of 
the skin and mucous membrane, it is usually the hard type, 
resembling microscopically an ordinary cutaneous wart. 
Not often multiple. Generally lobulated and on account of 
its usual location is constantly irritated, hence is supposed to 
be the starting point of a malignant change. One orifice 
only is affected, as a rule. 

Treatment. — Removal by surgical measures is usually 
preferable. 

Nasal Cavity. — Papilloma is probably of infrequent oc- 
currence in the nasal cavity. When present, the favorite 
location seems to be the inferior turbinate, lower and an- 
terior portion of the septum and the membrane of the ves- 
tibule. Usually of the hard form, resembling in microscopic 
structure the cutaneous wart. It is very vascular and has a 
tendency to ulcerate. It is not often multiple, and is usually 
small. 

Symptoms. — Sensation of irritation, and frequently a 
copious discharge. Some pain may be present at times. If 
the growth obtains sufficient size, obstruction of the nasal 
cavity may result. Slight hemorrhage may also occur at 
times. As a reflex, asthmatic cough has been noted. When 



Papilloma. 245 

there is much ulceration and hemorrhage, a malignant 
change may be possible. 

Treatment. — Complete removal of the growth by sur- 
gical means. Reduction of the size, and even complete dis- 
appearance of the growth, has occurred by the repeated ap- 
plications of a saturated solution of salicylic acid in thuja. 

Nasopharynx. — But few cases have been reported. The 
location is the posterior inferior border of the inferior tur- 
binate. It resembles villous papillomata. 

Symptoms. — Practically the same as a foreign body in 
this location, causing a rhinopharyngitis. -If of considerable 
size there is impeded nasal respiration, and possibly occlu- 
sion of the Eustachian orifice. A persistent hacking cough, 
and the sensation of a foreign body in the nasopharynx. 
Nasal polypi are reported as being present in these cases. 

Treatment. — Removal of the growth. 

Pharynx. — The most frequent location for papillomata 
is the free border of the faucial pillars, the uvula or the ton- 
sils, although they may occur on any portion of the pharyn- 
geal membrane. The growth may be single or multiple, and 
as a rule it is of the hard type, usually following or asso- 
ciated with inflammatory conditions. 

Symptoms. — Such as would naturally follow. 

Treatment. — Removal by cutting forceps, care being 
taken not to injure any more tissue than necessary for com- 
plete excision. 

Larynx. — Here papillomata are the most frequent of be- 
nign tumors. On account of the location or through irritat- 
ing applications, the -site of this growth may become malig- 
nant. The varieties of papilloma described depend upon 
the amount of fibrous tissue and the implication of the sub- 
epithelial structures. The tumors may occur at any age, 
they may be congenital, multiple or single, pedunculated or 
sessile, and vary in shape. Usually they are situated at the 



246 Nose, Throat and Ear. 

anterior angle or portion of the vocal cords, although the 
ventricular bands or epiglottis may be the site. The varia- 
tion in size depends usually upon the length of time of 
growth. In adults the tumors are slow in growth, and, as 
a rule, are in the supraglottic region. In children the 
growth is rapid, and any portion of the larynx may be in- 
vaded. 

Symptoms. — Interference with natural phonation is the 
most marked symptom. This depends upon the location and 
size. When located in the aryepiglottic folds, epiglottic 
folds, or the ventricular bands, no distinct change in the 
voice may result. Respiration may be unimpaired. Spas- 
modic contraction of the laryngeal muscles may occur in 
children. Usually the size of the tumor influences the res- 
piratory action. When pedunculated and resting on the 
vocal cords, dyspnea may occur. When above the cords, 
dyspnea is most marked on inspiration ; when below the 
cords, on expiration, but spasm of the glottis may result in 
either case. Inflammation of the larynx usually accompa- 
nies the presence of a tumor. Hemorrhage is an infrequent 
symptom, unless the tumor is malignant. Pain is seldom 
present. 

Diagnosis. — Papilloma might be mistaken for the early 
stages of an epithelioma. Papilloma may occur at any age, 
and is a prominent, grayish white elevation with an irregular 
surface, but an unbroken epithelial covering, little or no dis- 
position to bleed, and located at the anterior portion of the 
vocal' cords. Epithelioma seldom occurs in the young, is 
not lobulated, and involves surrounding tissues. There is a 
disposition to bleed, and also to ulceration. It may be lo- 
cated in any part of the larynx, but the posterior portion of 
the vocal cords is the favorite location. 

Prognosis. — Unless the growth is of considerable size, 
or its location produces dangerous spasms or dyspnea, there 
is no immediate danger. Tracheotomy will relieve, even 



Adenoma. 247 

when such a condition presents. The removal of the growth 
is always to be advised. 

Treatment. — Operative measures are usually to be 
recommended. When the growth is small, touching it with 
a saturated solution of salicylic acid in thuja, and also giv- 
ing thuja internally, may be curative. In operative pro- 
cedures, the instrument required will depend upon the loca- 
tion and size of the mass. Y\ natever method is used, care 
should be exercised to remove the entire growth, with the 
slightest possible disturbance of the surrounding healthy tis- 
sue. Chemical caustics should not be employed. 

Adenoma. 

Anterior Nares. — Simple adenoma, excepting at the 
nasal orifice is practically a histological impossibility. 

Nasopharynx. — Simple adenoma of this region is very 
infrequent. 

Fauces. — A cystic adenoma may occur in this region, 
but usually the growth is an adenofibroma. The growth 
is similar to that of any benign mass, and is not often seen 
in adult life, even to the age of sixty. Most often found in 
females. 

Etiology. — It partakes of the characteristics of all be- 
nign growths in being slow in development. 

Symptoms. — Usually none excepting a sensation of full- 
ness. Occasionally, if occurring in the nasopharynx, there 
is some interference with nasal respiration. If in the 
faucial region, a desire to swallow, sometimes interference 
with deglutition, and very infrequently some pain. Hemor- 
rhage, when it does occur, is slight. 

Pathology. — An adenoma consists simply of a hyper- 
plasia of gland structure elements, its type being found in 
the acinous or tubular gland structures. By obstruction of 
the duct, it may become cystic and undergo mucoid degen- 
eration. Usually sessile. 



24.8 



Nose, Throat and Ear. 

DIFFERENTIAL DIAGNOSIS. 



Fibroma. 


Adenoma. 


Rapid development. 

Pain rather marked. , 

More interference with func- 
tion. 

Infrequent. 
Earlier life. 


Slow development. 

Pain slight. 

Slight interference with func- 
tion. 

Frequent. 

Middle life to sixty years. 



Treatment. — Surgical measures are necessary when the 
growth is of such proportions as to interfere with the nor- 
mal functions of the part. The growth should be dissected 
from its surroundings when encapsulated. If multiple, each 
individual mass should be removed. 

Larynx. — It is a question whether a true adenoma oc- 
curs here. Clinically, however, a growth within the vesti- 
bule of the larynx should be removed as soon as possible. 

Angioma. 

Nasal Cavity. — Infrequently found, but appears to pre- 
fer the septum. It is formed by the distention of vessels al- 
ready present, rather than by a new vessel growth. The 
distention is produced by changes in the walls of the ves- 
sels. The condition is most frequently seen in those of a 
lymphatic temperament. 

Symptoms. — Obstruction of the nasal cavity is the prin- 
cipal symptom. Pain is seldom present. When the growth 
is of considerable size, a mucopurulent discharge is present. 
Hemorrhage may occur, and occasionally is excessive, this 
being determined by the location of the angioma. De- 
formity of the nose seldom results. The varieties usually 
seen are the simple and cavernous. The simple are often 
congenital, and are generally small, with a comparatively 



Angioma 249 

smooth surface. The cavernous variety has larger vessels 
and the surface is rather irregular. Either variety is found 
most frequently in early life ; seldom, if ever, in old age. 

Diagnosis. — Pressure will markedly diminish the size 
of the growth. Pulsation is usually present, marked when 
it communicates with an artery ; slight with a vein. Slight 
manipulation will cause hemorrhage. The color varies from 
a light red to a'bluish red, the usual color being a dark red, 
on account of the growth communicating with both an ar- 
tery and vein. The color also varies according to the posi- 
tion of the tumor in the tissues. 

Prognosis. — Good, when properly removed. There is 
no tendency to recurrence. 

Treatment. — The cold wire snare is best in the majority 
of cases, but the work must be slowly done, on account of 
the tendency to hemorrhage. If the tumor is sessile, the 
loop can be held in position by transfixing the mass with a 
needle before tightening the loop. Ligation by means of 
strong silk ligatures, transfixing with several sutures, may 
also be employed. The stump should be cauterized with 
chromic acid, 20 per cent ; trichloracetic acid 1:2000; or 
salicylic acid ointment. In some few cases bipolar elec- 
trolysis has given good results. 

Fauces. — In the faucial region angiomata are seldom of 
the simple form, a mixed variety being generally found. 
The lateral walls are most frequently affected. As there is 
so much vascularity of this region, the Vessels of the tumor 
are usually of considerable size, and there is a decided tend- 
ency to hemorrhage. 

Symptoms. — The principal symptoms are a sense of ob- 
struction in the throat, pain on deglutition, and the liability 
of hemorrhage. 

Treatment. — Either electrolysis or the galvano-cautery, 
but in the removal of the growth care is necessary, as the 
liability of an excessive hemorrhage is to be remembered. 



5$d Nose, 'Throat and Kar. 

Pharynx and Uvula. — "Cruveilhier's plexus" is often 
the site of a varicosed tumor, and the hyoid fossa is also a 
favorite location for angioma. Angioma of the uvula is 
seldom seen. 

Symptoms. — When the tumor is of considerable size, 
there is a constant sense of discomfort or fullness in the 
throat, and usually an irritating cough. 

Treatment.- — Electrolysis or the galvano'-cautery. 

Tonsil. — Only a few cases have been reported. 

Treatment. — The cold wire snare, cutting slowly on ac- 
count of the profuse hemorrhage. 

Larynx. — Seldom found, but has been reported impli- 
cating the ventricular bands, epiglottis and the lingual sinus. 
The tumor is nearly always small, and of a bright red color, 
racemose and unilateral. 

Chondroma (Enchondroma). 

Nasal Cavities. — The term should be applied to carti- 
laginous tissue formations having their site in any portion 
of the nasal cavities or accessory sinuses, with the exception 
of the triangular cartilage of the septum. Chondroma, if 
of any considerable size, may cause deformity of the nose, 
and through pressure, absorption of the contiguous bony 
structures may result, invading even the orbit and cranium. 
) True chondroma are infrequently seen ; the favorite loca- 
tion is at the junction of the cartilaginous septum and an 
alar cartilage. The tumor is usually round and nodular, 
and occurs in early youth ; generally unilateral. 

Symptoms. — Impairment of nasal respiration depends 
upon the size of the tumor. When of considerable size it 
will cause an accumulation of secretion, which soon be- 
comes muco-purulent and offensive. Pain is seldom present, 
unless the location and size produce pressure. Being non- 
vascular there is no tendency to bleed. It grows very 
slowly. 



Chondroma (Knchondroma). 251 

Diagnosis. — Palpation with a probe will demonstrate a 
hard but slightly elastic mass. The texture of the tumor 
is hard and dense, immovable, usually of a pink or yellow- 
ish-white color. It may be round or irregular and nodulated. 
Puncture with a needle will differentiate from an osteoma. 

Prognosis. — This depends upon early recognition and 
removal, before deformity or bony absorption occurs. 

Treatment. — Complete removal by means of the knife, 
nasal drill, or saw. If of considerable si£e, an external 
operation may be required. This is true also when the 
growth originates in the accessory cavities. The hemor- 
rhage is slight. 

Naso-Pharynx. — Two cases only have been reported, 
both occurring in young adults. 

Larynx. — The favorite location is the cricoid cartilage, 
although the thyroid, epiglottis, and arytenoid cartilages 
may be affected. The tumor is sessile, immovable, and 
usually extends inward. It may be of sufficient size to pro- 
duce symptoms of dyspnea. A slightly hyperemic mem- 
brane usually covers the tumor, and hemorrhage, when it 
occurs, is from this membrane. 

Diagnosis. — The tumor is hard, dense, slightly lobulated, 
and slow of growth. 

DIFFERENTIAL DIAGNOSIS. 
Perichondritis. Carcinoma. Chondroma. 

A determinable cause, No cause No cause 

usually. 

Age not a factor Advanced age Early life, usually 

Onset sudden Slow Slow 

Acute local inflamma- Inflammation late Inflammation absent, un- 

tion. less the result of ob- 

struction. 
Edematous tendency Seldom, if present late. .Seldom, if present late. . 

early. 
Any of the cartilages Seldom below the Usually the cricoid car- 
glottis, tilage. 

Localized Disposition to spread, Localized 

and glandular in- 
volvement. 



252 NcoK, Throat and Bar. 

Prognosis. — Good if removed early. 

Treatment. — -If small the growths may be cauterized 
with chromic acid, or removed with cutting forceps. When 
large a thyrotomy may be necessary. 

Exostosis. 

Ziegler applies this term to either bony or cartilaginous 
growths. The variety arising from either bone or cartilage., 
and either partly cartilaginous or entirely bony, is termed 
connective-tissue exostosis. The variety which forms from 
cartilage only, is called cartilaginous exostosis or ecchon- 
drosis. The growths may be from the septum or turbinated 
bones, and are usually called crests, ridges, spurs, excres- 
cences, or redundancies. The connective tissue type may 
be located anteriorly on the triangular cartilage, or pos- 
teriorly on the vomer. At times the floor of the nose is the 
location, or the turbinates, especially the middle. When 
located on the turbinates, the growth is usually in the shape 
of a spur, or may extend entirely across the nasal cavity. 
It may have its site either in the bone or the periosteum, and 
is always covered with mucous membrane. Such- growths 
are always more or less sessile, no matter from which por- 
tion of the nasal structures they have their origin. They 
may be congenital, or the result of malformations, or of 
[traumatisms. On the septum, the cartilaginous spur usually 
presents the appearance of a short ridge close to the nasal 
floor. In the early stages it may be entirely cartilaginous, 
but later may become a compact bony structure, so that its 
removal with the ordinary nasal saw will be difficult. When 
the ridge extends to the posterior portion of the cartilage or 
invades the vomer, it may resemble a fold, the anterior por- 
tion being cartilaginous, the posterior portion bony, and al- 
ways covered with mucous membrane. A corresponding 
depression is usually found on the opposite side, and this 
must be taken into consideration in operative measures. 



Fibroma. 253 

Symptoms. — As a rule impeded nasal respiration is the 
most prominent, although in several cases the patients have 
complained of neuralgic pains in the frontal, orbital, or 
supraorbital regions, pressure on the exostosis starting or 
increasing the pain. 

Treatment. — Unless there is obstruction to nasal respira- 
tion, or a tendency to accumulation of secretion, or some re- 
flex irritation caused by its presence, removal is not neces- 
sary. AYhen operative measures are required, the mucous 
membrane should be carefully dissected up from the lower 
margin of the growth, and the projection removed by means 
of a saw, cutting forceps, or whatever instrument is appli- 
cable to the case. Local anesthesia should be induced prior 
to the operation. After the removal of the growth, the flap 
of mucous membrane should be made to cover the traumatic 
surface. Excepting in cases of severe hemorrhage no pack- 
ing of the cavity is required. The necessity for douching 
the nose repeatedly after the operation depends upon the 
case, but, as a rule, I consider it better surgery to inter- 
fere as little as possible, as healing is more likely to progress 
favorably without the use of solutions, which simply macer- 
ate the tissues and encourage ulceration or sloughing of 
tissue. As a rule, the healing process will be completed in 
from ten days to two weeks, but some systemic conditions 
may retard the process. When ulceration does occur, the 
surface may be touched with a saturated solution of Lloyd's 
salicylic acid and thuja, or thuja and Lloyd's hydrastis. In- 
ternally, the use of potassium bichromate will check the 
ulcerative process. 

Fibroma. 

Nasal Cavities. — In the nasal cavity a true fibroma 
may occur, but it is usually a mixed type of tumor. The 
structure is the same as of- this growth in other regions. 
The site is the submucosa. Histologically the growth dif- 
fers from mucous polypi in the small amount of matrix; 



254 Nose, Throat and Ear. 

clinically, they are distinguished by the deep red color, lack 
of translucency, firmer resistance to the probe, lobulated and 
irregular appearance, and in usually being sessile. Fibro- 
mata usually have their site from the posterior and inferior 
margin of the middle turbinate. If located in the anterior 
space, they may arise from the lower margin of the middle 
turbinate, or from the anterior portion of the superior tur- 
binate. Very seldom do they have their origin from the 
septal tissue, and only a few cases have been reported as 
having the floor of the nose for the origin. The shape 
varies according to location. In the posterior portion it 
may extend backwards into the post nasal space, and be 
pedunculated. In the anterior portion of the nasal cavity 
the growth is usually smaller, more elongated, and possibly 
more irregular in outline. If degenerative processes take 
place, or much irritation of the mass occurs, a malignant 
growth may occur. Males are most frequently affected, and 
between the ages of fifteen and thirty. 

In the early stages there is little, if any, pain, but when 
the tumor attains considerable size, the pressure on adja- 
cent structures causes pain. A muco-purulent discharge is 
usually present, and hemorrhage, which may be frequent or 
severe, may occur. The obstruction to nasal respiration de- 
pends upon the size of the tumor. More or less complete 
loss of smell usually results, as well as a nasal twang to 
the voice. • When the tumor attains considerable size nasal 
deformity occurs, the so-called "frog-face" resulting from 
the pressure upon the nasal bones. Fibroma are often asso- 
ciated with mucous polypi. 

Diagnosis. — The sense of touch by the use of a probe, 
and the appearance of the tumor by anterior or posterior 
rhinoscopy, are the principal methods of diagnosis. 

Prognosis. — This depends upon the early recognition of 
the growth. If deformity of the nose has occurred, or much 
change in the structures has resulted, the prognosis is more 
unfavorable. 



Fibroma. 255 

Treatment. — Removal by the cold wire snare is best 
when it can be used. The work should be by slow con- 
traction of the loop, to prevent hemorrhage. If hemorrhage 
does follow, the usual methods of controlling it should be 
employed. The use of cocaine or suprarenal products is 
to be decried, as the danger of secondary hemorrhage is 
increased. 

Nasopharynx. — True fibroma may have their origin in 
the post-nasal space, the basilar process of the occipital bone 
being the favorite location. It may extend upward, caus- 
ing displacement of bony tissue, or downward filling the 
nasopharyngeal space and even the pharynx. 

Symptoms. — The size of the growth and its direction 
frequently causes a variation of the symptoms. When up- 
ward, they do not vary particularly from those where the 
growth is in the posterior portion of the nasal cavity, ex- 
cepting there may be more of a sensation of pressure over 
the bridge of the nose, and a more continuous headache. 
When the growth is downwardj there is an early change in 
the character of the voice, a sensation of some foreign body 
in the pharynx producing a constant desire to swallow, sen- 
sitiveness of the pharyngeal tissues, and often a slight 
hemorrhage. Pressure paralysis will cause some impair- 
ment of the action of the soft palate and uvula. 

Diagnosis. — Palpation with the finger, and posterior 
rhinoscopy. 

Prognosis. — The early recognition is important, as in 
this location the danger to the patient is greater than when 
occurring in the nasal cavities. 

Treatment. — When possible to do % so, the complete re- 
moval of the growth by the cold wire snare is best. 

Tonsil. — A few cases have been reported, and usually 
are of the fibroplastic variety. They are slow in developing, 
and the symptoms are similar to those of enlarged tonsils. 

treatment. — When not very vascular, the mass may be 



256 Nose, Throat and Ear. 

removed with a tonsillotome, or better, by the cold wire 
snare, as this will usually not be followed by excessive 
hemorrhage. If adhesions are present between the tonsil 
and faucial pillars, they should be divided before operating. 

Larynx. — Fibroma of the larynx usually occur from 
the tissue of the vocal cords. Usually, on account of- the 
location, the growth is not large. 

Symptoms. — As a rule, the first symptom is interference 
with phonation. This may vary from slight hoarseness to 
complete aphonia. Occasionally diplophonia, or double 
voice, occurs, but this is only when the growths are small. 
The respiration is interfered with in nearly one-third of 
the cases, and often there is dyspnea. The presence of the 
growth frequently causes cough. Pain is not often present 
Very infrequently is there any effect produced on the act 
of swallowing. Hemorrhage does not often occur, unless 
ulceration takes place, which is infrequent. Found usually 
in youth or early adult life, seldom in the adult or aged. 
Nearly always single and sessile. 

Diagnosis. — The smooth vascular surface. Sometimes 
a microscopical examination is necessary to differentiate 
from papilloma. 

Prognosis. — Favorable as regards removal, but a- change 
in the voice may be permanent. 

Treatment. — As a rule, tracheotomy must first be per- 
formed, after which the growth may be removed by biting 
forceps and curette, but these operations should not be un- 
dertaken by the novice. 

Lipoma. 

Nares. — This form of tumor is infrequent in the an- 
terior nasal cavity. On the external nasal surface it is not 
uncommon. 

Nasopharynx, Pharynx, and Larynx. — This form of 
growth is seldom found. 






Osteoma. 257 

Treatment. — Removal is not difficult if a biting forceps 
or curette is used. 

Osteoma. 

Narks. — Osteomata of the nasal cavities may occur 
primarily from the bony or cartilaginous walls, or from 
some of the accessory sinuses, and project into the nasal 
space. Generally the site of the tumor is in the upper por- 
tion of the nasal cavity. The shape depends largely upon 
the pressure exerted by the surrounding structures. Two 
varieties are recognized, viz., eburnated and cancellous. 
Proliferation of the osteoblast generally commences in the 
periosteum. The cause is unknown. 

Pathology. — Although the two divisions, eburnated and 
cancellous, are recognized, they are generally found to- 
gether, one form predominating. When an osteoma has 
its origin in an accessory sinus, the ethmoid is the favorite 
cavity. The growth is usually single and irregular in shape, 
but the conformation is influenced by its location. 

Symptoms. — The size and location of the growth deter- 
mines the degree of nasal obstruction. Headache is often 
severe, and many of the early symptoms may be mistaken 
for sinus lesions. Epistaxis often occurs and a muco-puru- 
lcnt discharge, usually offensive, is found in many cases. 
Pain is frequently present. Deformity of the upper part of 
the nose is often found. Invasion of the orbit may occur 
when the growth extends upward through the ethmoid cells. 

Diagnosis. — Ordinarily there is little difficulty in recog- 
nizing the tumor, and by the use of a probe or needle its 
bony character can be determined. The growth of a simple 
osteoma is usually slow. If there is a disposition to rapid 
growth, a sarcomatous element must be thought of. A sar- 
comatous change usually occurs at the base of the tumor. 

Prognosis. — Usually favorable, especially, if removed be- 
fore invasion of the accessory sinuses, or before facial de- 
formity has resulted. 

17 



258 Nose, Throat and Bar. 

Treatment. — When seen early, or if confined to the nasal 
space, bone cutting forceps, saw, or gouge, according to the 
character of the growth. As a rule, in the growth by ex- 
tension, or if its origin is in an accessory sinus, an ex- 
ternal operation will.be necessary. 

Myxoma (Nasal Polypus). 

Myxoma is a low grade of adult connective tissue tumor. 
Considerable confusion has occurred regarding these 
growths in the nasal cavities, as a result of not differentiat- 
ing between mucoid and myxomatous degeneration of tissue, 
and an actual neoplasm. Myxomatous degeneration, espe- 
cially of the lower portion of the middle turbinated mucous 
membrane, often occurs. That a passive congestion, fol- 
lowed by watery infiltration into the connective tissue, and 
eventually absorption of connective tissue cells may result 
in hydropic degeneration of some cells and myxomatous or 
gelatinous change in others, producing a polypoid appear- 
ing growth, is considered unquestioned. Simple chronic 
inflammation may produce the same result. 

Etiology. — Myxomata, simple or mixed, are the most 
frequently seen of nasal tumors. The cause of these growths 
is obscure, but, as a rule, they are most frequently found 
in persons having tortuous or narrow nasal cavities. Sex 
does not appear to be a factor. The ages in which they 
are oftenest found is between fifteen and thirty. They may 
be single, but most frequently are multiple. Usually they 
are pedunculated. Both nasal cavities are usually affected. 
Damp weather will increase the size of the tumors. Ther- 
mometric changes do not seem to have any influence. The 
general systemic condition does not appear to be a factor, 
although the impaired nasal respiration leaves its usual 
effect upon the health of the patient. The usual origin of 
myxomata is the middle turbinate, although they may have 
their site from any portion of the nasal tissue. The shape 



Myxoma (Nasal Polypus). 259 

and size of the growth are largely influenced by the loca- 
tion, without reference to its being pedunculated or sessile. 
In some cases the tumor is so large as to project from the 
anterior naris when the pedicle is generally found to be long 
and slender. Myxoma usually present a glistening, whitish 
gray, translucent appearance. Palpation with a probe will 
cause disappearance of the glistening spot, the growth be- 
ing easily indented having an elastic sensation. Generally the 
surface is smooth, and blood vessels are distinctly visible. 




Fig. 63. Myxomata having their origin from the superior turbinate, 
and one from the inferior turbinate. 

The size is variable, being from the size of a pin head to 
sufficient to fill the entire nasal cavity. When the origin is 
from the floor of the nose or septum, usually but one is 
found. If from the middle or superior turbinates, or the 
roof of the nose, they are generally multiple. If from the 
septum, they are usually a mixed "form, angiofibromyxoma. 
Pathology. — A true myxoma consists of a thin cover or 
sac of connective tissue, enclosing a mucoid substance with 
spindle-shaped cells and fine connective tissue trabecular 
Thest growths generally partake of the mixed type, and 
fibrous connective tissue stroma is found (myxofibroma). 



260 Nose, Throat and Ear. 

Symptoms. — These vary according to size, number, and 
location of the growths. A nasal twang is often present, 
with impeded nasal respiration and increased secretion, 
which may be offensive. When there is much nasal obstruc- 
tion, the various pharyngeal and laryngeal phenomena are 
present which characterize mouth breathers. If located in 
the upper portion of the nasal cavity, pressure may be made 
on the lacrimal duct, interfering with the free exit of secre- 
tion. In some cases deformity of the nose may result. If 
the tumor occludes the opening of the antrum of Highmore, 
complications of this region may follow. Reflex symptoms 
may result from the pressure of these tumors, as asthma, 
laryngeal or pharyngeal, etc. The sense of smell is usually 
impaired or destroyed. 

Diagnosis. — Inspection or palpation with a probe is 
usually sufficient, although in some cases, when the growth 
is located well back in the nasal cavity, posterior rhinoscopy 
is necessary. Often a polypoid hypertrophy of the border 
of the superior turbinate, when the body is long and project- 
ing, may be found. This myxomatous, or mucoid degen- 
eration, is generally associated with, or follows, simple 
chronic or hyperplastic rhinitis. It is easily differentiated 
from true myxoma. 

Prognosis. — Good, only for a marked tendency in some 
cases for recurrence of other tumors near the original loca- 
tion, especially when there are bony projections, as are often 
found in the upper portion of the nasal cavity. 

Treatment. — Removal by means of the cold wire snare is 
preferable, but in those cases where it can not be used, a 
biting forceps may be employed. As little disturbance of 
the surrounding tissue as possible should be made, as this 
may form a site for a new growth. The use of cauterant 
preparations is to be condemned. The application of salicylic 
acid ointment to the site of the growth after removal is 
beneficial. 



Fibrous Polypi; Myxofibroma. 261 

Fibrous Polypi; Myxofibroma. 

This form differs only from myxoma in having a fibrous 
connective tissue framework. 

Etiology. — Essentially the same as true myxoma. 
Usually occurs between the ages of twenty and thirty, sel- 
dom found in the aged or in children. The tumor is quite 
vascular, generally sessile, involves deeper structures, and 
there is usually more hemorrhage when removed than in 
myxoma. There appears to be a type where there is a dis- 
position to reformation from adjacent tissue, w r ith a tend- 
ency to sarcomatous development (myxosarcoma). The 
growth probably does not degenerate into a sarcoma, but 
furnishes a favorable nidus for its development. Fibro- 
myxoma seldom have their origin from the septum or floor 
of the nose. They may be single or multiple, and vary in 
shape and size. 

Pathology. — The microscopic appearance varies from 
myxoma according to the amount of fibrous connective tis- 
sue stroma present. 

Symptoms. — Practically the same as myxoma. 

Diagnosis. — By inspection and probe. 

Prognosis. — Usually favorable, if thoroughly removed 
early. The tendency is to recurrence. 

Treatment. — The cold wire snare or alligator jaw for- 
ceps, disturbing the normal mucous membrane as little as 
possible, is the most satisfactory method. With the snare, 
the wire should be tightened slowly, as this procedure de- 
creases the amount of hemorrhage. Healing is usually com- 
plete in from five to seven days. The introduction of a 
cotton tampon coated with salicylic acid ointment is usually 
all the after treatment required. In only exceptional cases 
have I found it necessary to use washes. 



262 Nose, Throat and Ear. 

Mucocele. 

Synonyms. — Gelatinous or Mucous Polypi. 

Etiology. — These growths are practically retention cysts, 
the origin being the mucous glands. They are usually found 
in cases having abnormal conditions of the nasal cavities, as 
septal deflection, cartilaginous or bony growths, etc. 

Pathology. — That of a retention cyst. The contents of 
the cyst are very gelatinous, contain albumin and mucin, 
and are either fluid or semi-fluid. 

Symptoms. — Similar to nasal myxoma. As the tumors 
are usually sessile, the circulation is more obstructed. As 
a result, the external surface of the nose is liable to be swol- 
len, slightly edematous and often with partial or complete 
obliteration of the labionasal fold. 

Diagnosis. — The growths are usually in the superior por- 
tion of the nasal cavity. Cocaine has no contractile in- 
fluence. 

Prognosis. — Good. 

Treatment. — Open and curette, so as to destroy the sac. 
Apply to the surface either thuja and hydrastis aa. or 
salicylic acid ointment. 

Nasopharynx. — In this region the tumors are usually 
associated with mucocele of the anterior nares. The cause 
arid pathology are the same as of the anterior nares. 

Symptoms. — These are similar, excepting the probability 
of affecting the Eustachian tubes, producing middle 
ear disease. Irritation of the pharynx, larynx, or 
bronchi often result. The location is most frequently on 
either the posterior inferior margin of the middle turbinate, 
or the same location on the inferior turbinate. 

Treatment.— Removal by means of the cold wire snare, 
either with the curved canula, passing it through the mouth 
and back of the soft palate, or if possible, passing the 
straight canula through the nasal chamber. It is sometimes 
possible to use the alligator- jawed forceps through the 



Mucocele. 263 

nasal cavity, locating the tumor with the fhinoscopic mir- 
ror. 

Larynx. — The two forms, myxofibroma and fibromyx- 
oma, are clinically identical, although differing somewhat 
in their microscopic aspect. The tumors are variable in 
size, generally single, and may be pedunculated, but usually 
sessile. Their origin may be from any portion of the larynx, 
but is generally from the upper portion. They present a 
semi-translucent, pinkish gray appearance, with blood ves- 
sels clearly discernible. These growths are most frequent 
in middle life, and are found oftener among those who over- 
use the voice. Seldom recur after removal. When there 
is considerable fibrous tissue present, the appearance is that 
of papilloma. 

Pathology. — Histologically the appearance is that of na- 
sal fibromyxoma, only the capsule is more fibrous. 

Symptoms. — Identically the same as a movable foreign 
body. Changes in the tone and character of the voice result. 
When the tumor is movable and located below the vocal 
cords, spasmodic interruption in phonation often results 
on account of the tumor being forced upward between the 
vocal cords. Depending upon the size and location of the 
growth, there may be difficult respiration. Tracheotomy 
may be necessary in some cases. Pain or hemorrhage are 
infrequent. 

Diagnosis. — It is often difficult to obtain a laryngoscopic 
view, even with cocaine anesthesia, on account of the hy- 
persensitive condition of the parts. The attachment and 
appearance will aid, and the microscopic examination will 
determine its benign character. 

Prognosis. — The early recognition and removal of the 
growth will be favorable. The location and size must also 
be considered. The most distressing symptoms, however, 
can usually be relieved. 

Treatment. — The removal of these growths should not 
be attempted excepting by a skilled operator, as the opera- 



264 Nose, 'Throat and !Ear. . 

tion is a difficult one to perform. The damage which may 
result through incompetent manipulation may be more 
serious than the original disease. When possible to perform 
an intralaryngeal operation, a local anesthetic is preferable. 
The laryngeal mirror to guide the forceps should always be 
used. The forceps employed will depend upon the loca- 
tion of the tumor, and should never be employed excepting 
under full illumination with the laryngoscopic mirror. 

Embryonic Epithelial Tumors. 

Carcinoma. 

Nasal Cavities. — Carcinoma in this region is generally 
the squamous-celled variety of epithelioma. It is infre- 
quently found, but when it is, it is usually primary, and in- 
vades the contiguous tissues. The origin may be the 
mucocutaneous junctures, extending into both surfaces. 
As a rule, the tumor commences as a small nodular area 
of infiltration, extending rather rapidly, and with a tend- 
ency to early ulceration. 

Etiology. — The cause is largely conjectural. The varie- 
ties of carcinoma all belong to the epithelial type and are em- 
bryonic. Predisposition to the disease may be inherited. 
Sonstant irritation is recognized as a factor, while trau- 
latism often leads to sarcoma. Carcinoma of the nasal 
cavities is usally located in the anterior portion. 

Pathology. — The miscroscopic appearance depends 
largely upon the development of the tumor. In some cases 
there is a large preponderance of normal tissue, as a result 
of the tendency to increase through the lymphatics. The 
development of the growth eventually resembles scirrhous 
carcinoma. The growth is practically characteristic of all 
carcinomatous tumors. 

Symptoms. — An early symptom is the pain which usually 
is not constant, but when present is lancinating. The color 
and odor of the mucopurulent secretion is almost character- 



Embryonic Epithelial Tumors. 265 

istic. Hemorrhage is not as free as in sarcoma. Nasal res- 
piration is not much impaired in the early stages, but later 
may be considerable. The ethmoid and sphenoid cells are 
sometimes implicated. If this occurs, vision is usually af- 
fected, and in some cases the growth may cause an exoph- 
thalmos. Enlargement of the lymphatics is inconsiderable 
in primary carcinoma of the nose, but when secondary, or 
if there is a general carcinomatous condition, the glands are 
often affected. The ulceration is deep and ragged, and 
there is a thin grayish brown, offensive discharge. The 
characteristic cachexia increases with the advance of the 
disease. 

Diagnosis. — Not always easy even by microscopic exam- 
ination, unless the section is taken before ulceration com- 
mences. When taken from an ulcerated surface, it is prac- 
tically impossible to differentiate from sarcoma, or an ulcer- 
ation from a simple inflammatory process. The secretion 
in carcinoma is not adherent to the surface, but in tubercular 
lesions it is tenacious, stringy, and adherent. 

Prognosis. — Always guarded. If complete extirpation 
is impossible, it is better left alone. The action of the X- 
rays, or the Finsen rays seems to promise more than any 
other procedure. 

Treatment. — As stated, operative measures, unless re- 
sorted to early, are ineffective. Such measures as will con- 
duce to the comfort of the patient should be employed. 

. Nasopharynx. — In- this region primary carcinoma is 
infrequent. If it does occur, the soft palate is usually im- 
plicated. 

Symptoms. — The growth is slow, and the interference 
with nasal respiration is gradual. Pain in the early stages is 
slight, but gradually increases in severity. Secretion is in- 
creased, and after ulceration occurs is mucopurulent and 
stained with blood. The glands of the nasopharynx, 
pharnyx, and cervical region are finally involved. 

Diagnosis. — Certain only by microscopic examination. 



266 Nose, Throat and Ear. 

Prognosis. — Unfavorable. Death usually results in from 
one to three years. 

Treatment. — Usually only palliative. In some instances 
a radical operation may be more or less successful. 

Sopt Palate;.— In this structure, carcinoma usually pre- 
sents the appearance of epithelioma, and may be cylindrical, 
squamous-celled, or tubulated. Usually occurs after middle 
age. Is found most frequently in males. The origin of the 
growth is in the muciparous glands, and for this reason the 
tubulated variety is most common. Carcinoma of the velum 
is generally primary, and is often confined to this tissue, 
but in the later stages of the disease it sometimes invades the 
adjacent tissues. 

Symptoms. — The first symptom is usually a diminished 
movement of the velum. As the growth increases the mo- 
tion is still more lessened, and food often regurgitates into 
the nasopharynx. Phonation is impaired. The adjacent 
mucous tissue is often slightly inflamed and some edema 
may be present. If the adjacent tissues are affected, and 
the growth is of considerable size, often severe laryngeal 
obstruction may result, causing sufficient dyspnea to make 
tracheotomy necessary. Pain is neither severe nor constant, 
excepting in the later stages, and where there is implication 
of adjacent tissue. Ulceration is usually absent in primary 
carcinoma of this structure. 

Diagnosis. — Microscopic examination is the only sure 
differentiation between carcinoma, papilloma, and adeno- 
fibroma. 

Prognosis. — Usually fatal, as recurrence is almost sure, 
although it may not recur within a year. 

Treatment. — Palliative, so far as now known. 

Pharynx. — In this region the growth usually begins 
on the posterior wall, follows the lymphatics, invading the 
lateral and anterior walls, and generally the tonsils, velum, 
and nasopharynx. Is often associated with carcinoma of the 
esophagus. 



Embryonic Epithelial Tumors. 



267 



As a rule the growth is the squamous-celled, epithelial 
type, but occasionally it is scirrhous. 

Symptoms. — -Pain is infrequent in the early stages, but 
after ulceration, which occurs early in this region, the pain 
is quite constant. The act of deglutition increases the pain, 
which is lancinating and radiating. There is impairment 
of phonation. The secretions are very profuse, white and 
fetid after ulceration begins. If the growth is of the epi- 
thelial type, it is soft and spongy. When of the scirrhous 
form, it is first a hard, irregular tumor. In the early stages 
the mucous membrane covering either form is about normal 
in appearance, but after ulceration begins it is entirely lost. 
In the scirrhous form especially, the cervical glands are en- 
larged early. When the tumor is in the lower pharyngeal 
region and restricted to the posterior surface, it is usually 
fungoid. The outline is irregular, and the_ surrounding 
tissues swollen. The cervical glands are not involved 
as much when the growth is in the lower portion of the 
pharynx. 

DIFFERENTIAL DIAGNOSIS. 



Carcinoma. 


Fibroma. 


Syphilis. 


Tissues adjacent to 
pharynx usually in- 
involved. 


Confined to pharynx. 


Probably other mani- 
festations ; ulcera- 
tion may be single 
or multiple. 


Sessile. 


Pedunculated. 


Indurated. 


Irregularly firm. 


Dense and firm. 


Somewhat firm. In- 
flammatory areas 
surrounding lesion. 


Ulceration. 


None. 


Ulceration. 


No tendency of ulcer 
to heal. 




Tendency to heal. 


Remedies produce no 
effect. 


Remedies produce no 
effect. 


Yield to proper rem- 
edies. 


Pain severe. 


Pain absent. 


Pain on irritation. 



268 Nose, Throat and Ear. 

Prognosis. — Fatal. 

Treatment. — Palliative. 

Tonsil. — Carcinoma of the tonsil is very seldom seen. It 
is usually the squamous or cylindrical-celled epithelioma. 
In nearly all cases it is secondary, extending from the pil- 
lars of the fauces or the tongue. Early in epithelioma there 
is ulceration of the tonsil and enlargement of the cervical 
glands. Seldom occurs under the age of forty. The tumor 
is usually small, and invasion of surrounding structures is 
rapid if primary. The fetor from the ulceration is character- 
istic. The cachexia of wasting diseases and malnutrition is 
present. The secretion is excessive, and becomes more or less 
purulent and very irritating as ulceration progresses. Pain, 
increased by swallowing, is marked. When the deeper 
tissues are involved, a severe or even fatal hemorrhage 
may occur. As the disease progresses the cachexia in- 
creases, and there is a tendency to edema of the glottis. 
The voice is much changed. 

Treatment. — Same as for sarcoma. 

Pharynx. — There is a diversity of opinion regarding 
primary malignant tumors of this structure, microscopic 
examinations not always positively determining their char- 
acter. Carcinoma of the laryngeal tissues may have a nod- 
ular, papillary appearance. Later the true character of the 
tumor may be apparent. The difficulty experienced in mak- 
ing a microscopic examination is accounted for because of 
these growths often having a papillomatous surface, and the 
portion removed simply includes these nodules. There ap- 
pears to be a hereditary disposition to laryngeal carcinoma 
in about twenty-five per cent of cases. 

Pathology. — Usually epithelial in variety, squamous- 
celled or the tubulated type most frequently. The latter 
is really an adenocarcinoma. Any portion of the larynx 
may be involved, but the primary site is usually in the ven- 
tricular bands, vocal cords, or epiglottis. When the tumor 



Embryonic Epithelial Tumors. 269 

is intrinsic, it does not often involve the surrounding tis- 
sue, and the glands of the neck are not affected. This is 
probably because death results comparatively early in the 
disease. When the tumor is extrinsic, or in the epiglottis, 
the surrounding structures are affected, and also the glands 
of the neck. 

Symptoms. — In the early stages, the symptoms do not 
vary essentially from those of a benign growth. The site of 
the tumor will determine early changes in the voice. When 
of the vocal cords or ventricular bands, the vocal change will 
be early. The change is more of power than of register 
or tone, and_ is rather characteristic. Pronounced dyspnea 
may occur as the growth increases. When intrinsic, dys- 
phagia may be present, which accounts for the accumula- 
tion of secretion in the mouth. The glands may be af- 
fected. In the extrinsic form this occurs early, but in the 
intrinsic, when it occurs, it is a late development. Usually 
ulceration occurs in from three to six months. Hemor- 
rhage occurs with the ulcerative process, gradually increas- 
ing with the progress of the disease. It is seldom that the 
ulceration involves the deeper structures, but when it does, 
interstitial necrosis follows. Prior to ulceration the secre- 
tion is excessive, but otherwise not abnormal. When ulcer- 
ation takes place the secretion becomes mucopurulent and 
tenacious. It may be streaked with blood, greenish or gray- 
ish-brown in color, and may contain necrotic tissue and pus 
cells. The breath has an offensive, musty odor. Pain is 
usually a constant symptom, although when the growth 
is intrinsic it does not develop as early, and is not as 
pronounced. The cancerous cachexia is more marked in the 
extrinsic variety. 

Diagnosis. — The diagnosis is usually difficult, as it is 
often almost impossible to make a satisfactory laryngo- 
scopy examination, even of a healthy larynx. The location 
of the tumor, the ulcer, and glandular enlargement are aids. 



270 Nose, Throat and Ear. 

Occasionally a specimen can be obtained for microscopic 
examination, but this piece should not be taken from the 
ulcerative portion. Usually the secretion is not adherent 
to the tumor, while it is tenacious, stringy, and adherent 
in tubercular lesions. 

Prognosis. — Unfavorable, as there is a recurrence in 
the majority of cases. 

Treatment. — Radical operative measures, when made 
early, may in some cases prove effective. When the dis- 
ease has progressed to the ulcerative stage, palliative means 
may give relief from the most painful symptoms. Keeping 
the parts as clean as possible by the use of disinfecting 
and alkaline solutions will diminish the discomfort of 
the patient, and may partially lessen the disagreeable odor. 

Embryonic Connective-tissue Tumors. 

Sarcoma. 

NasaIv Cavities. — Sarcoma in this region is usually 
secondary. Sarcoma of the nasal cavities may appear at any 
age, usually before forty. The development is rather slow. 

Pathology. — The origin is in the deep connective tissue, 
spreading to the mucous surface. When the growth is 
rapid, it is generally of the small round-celled variety. Na- 
sal sarcomata are most frequently of the large-celled type, 
and grow slowly. The growth originating usually in the 
deeper structures, the mucous membrane covering the, tumor 
is normal until the mass nears the surface, when the mucous 
membrane becomes thinner, with flattening of the epithelial 
cells. Fibrous tissue is not often found in the tumor, the 
cells being supported by a fibrinoplastic intercellular ma- 
terial. The growth is nodulated, generally soft and almost 
semifluctuating, the firmness of the growth depending upon 
its location. It presents a fungoid appearance. 

Symptoms. — Obstruction of the nasal cavity is the first 






Embryonic Connective-tissue Tumors. 271 

symptom. Prior to ulceration the catarrhal discharge does 
not vary from that found in any case of impeded nasal 
respiration.* After ulceration begins, which is usually late, 
and is coincident with increased vascularity, the secretion 
assumes a mucopurulent character, is stained with blood, and 
very offensive. Profuse hemorrhages frequently accompany 
this stage. Nasal deformity and pain depend upon the lo- 
cation. The pain is slight when the soft tissues only are 
affected, but when there is bony structure supporting the 
infected tissues, the pain is severe. This is very marked 
when the accessory cavities are involved. 

Diagnosis. — A positive diagnosis is possible only by a 
microscopic examination of some of the tumor, in conjunc- 
tion with the clinical history. Any of the nasal tissues may 
be affected. 

Prognosis. — Unfavorable. If recognized early an oper- 
ation which will completely remove the tumor may give fair 
results, as in this location the prognosis is better than when 
sarcoma is located elsewhere in the body. 

Treatment. — Complete destruction of the tumor in the 
early stage is the best procedure. Currettage or the galvano- 
cautery are preferable. None of the morbid tissue should be 
left, or the operation will increase the destructive process. 
Owing to the vascular structure, excessive hemorrhage may 
occur. This should be controlled by plugging the nasal 
cavity with gauze. When the tumor involves surrounding 
structures, an external operation will be required. 

Nasopharynx. — Sarcoma in this region is rather infre- 
quent. Males are more often affected than females. The 
usual age is between forty and fifty, although no period of 
life seems exempt. The origin is in the submucosa over the 
basilar process of the occipital bone. The tendency of the 
growth is usually downward,, and presents a lobulated ir- 
regular surface. The sarcoma is nearly always of the small, 
round-celled variety, which grows rapidly and in a short 



272 Nose, Throat and Ear. 

time invades the pharynx. The bony tissues are not often 
involved. The tumor is soft and fungoid. In some in- 
stances it Jjas extended upward, invading the sphenoid or 
sphenomaxillary sinuses. 

Symptoms. — The early symptoms do not differ essen- 
tially from those of any impediment to nasal respiration, 
but in a short time the secretion becomes bloody and of- 
fensive. Ulceration and hemorrhage rapidly develop. 
There is impaired general health, the result of both the im- 
peded nasal respiration and the difficulty in swallowing. 
As a result of extension to the Eustachian orifices, the hear- 
ing is impaired. Until the tumor is of considerable size, 
the pain is usually not severe. 

Diagnosis. — Sometimes difficult, but the rapidity of the 
growth, lobulated appearance, soft sensation on palpation, 
and exceeding vascularity will assist in the diagnosis. A 
microscopic examination of a portion is also an aid. In 
early life the development is usually rapid, as it is nearly 
always the small round-celled variety. When of the large- 
celled type, the development is slower. The tendency to 
recurrence after operative measures is marked. 

Treatment. — Practically, palliative measures are all that 
can be employed, as radical operations usually prove un- 
availing. In some cases an excessive hemorrhage may re- 
sult from the ulceration, requiring the employment of styp- 
tics or the galvano-cautery. Such measures as will sustain 
and improve the general condition should be employed. 

Fauces, Pillars, and Soft Palate. — Sarcoma of these 
structures is generally of the mixed-celled variety, and is 
irregular in growth. Development is slow, and with a tend- 
ency to localization. If involvement of surrounding tissue 
occurs, it appears late and progresses slowly. Owing to the 
anatomical structure of the parts, ulceration is not always 
present. The deeper structures are very seldom involved. 
External manifestations of the disease are lacking. 



Embryonic Connective-tissue Tumors. 273 

Symptoms. — The symptoms do not vary materially from 
those of sarcoma of the nasopharynx, but the pain is less 
severe. Ulceration and hemorrhage are slight. Edema of 
the adjacent tissues is frequent. 

Diagnosis. — The clinical history and a microscopic ex- 
amination. 

Prognosis. — Guarded. Recovery is said to occur in 
thirty to fifty per cent of cases. There is a liability to 
recurrence. 

Treatment. — When possible, complete extirpation of the 
growth. Hemorrhage is sometimes so excessive that liga- 
tion of some of the larger arteries may be necessary. 

Pharynx. — Primary sarcoma in the pharynx is seldom 
seen, but when it does occur it is usually between the ages 
of thirty-five and fifty. 

Pathology. — The pathology of the growth here is sim- 
ilar to that occurring in other regions, excepting that it 
may, through invasion of the lymph spaces by sarcomatous 
cells, assume what is called lymphosarcoma. 

Symptoms. — These are of mechanical obstruction, and 
a constant sensation of a foreign body in the affected region. 
Difficulty in swallowing .and when the tumor is large, some 
dyspnea, more pronounced in the recumbent position. Prior 
to ulceration, there is increased secretion. When ulceration 
takes place, the secretion is tenacious, stained with blood, 
and has an offensive odor. Pain is not severe, excepting 
on irritation produced by pressure or the implication of sur- 
rounding tissues. Hemorrhage is usually not severe. Nasal 
respiration is impeded and there is marked change of voice. 
Congestion and edema of adjacent tissue results. The 
cachexia is probably produced as much by the inability to 
take nourishment, as by the disease. 

Diagnosis. — Clinical history in conjunction with a micro- 
scopic examination of the growth. The portion excised 
should never be taken from the ulcerating surface. 
18 



274 Nose, Throat and Ear. 

Prognosis. — Unfavorable. It is only a question of time 
until the disease results fatally. 

Treatment. — Occasionally the tumor may be surrounded 
by a pseudo-capsule, and in such cases complete enucleation 
may be possible. Usually the surrounding tissues are af- 
fected, and the operation will be followed by a rapid recur- 
rence of the disease. If there is considerable dyspnea, a 
tracheotomy may give temporary relief. The treatment, 
however, is palliative in the majority of cases. The parts 
should be kept as free from secretion as possible. The 
juice of pineapple seems to relieve much of the pain and 
irritation caused by the raw surfaces. 

Tonsil. — Of malignant growths of the tonsil, primary 
sarcoma is the most frequent. It is generally of the lympho- 
sarcoma type. The tumor is prominent, projecting into the 
faucial region, and interferes with nasal respiration through 
obstruction of the nasopharynx. When of considerable size 
there is difficulty in swallowing, and clearness of articulate 
speech is lost. The growth is usually very vascular, with 
marked disposition to ulcerate, and hemorrhage may be ex- 
cessive or even fatal. The deeper structures are also liable 
to invasion. The cell formation may be of any variety, but 
when of rapid growth it is usually of the small round-celled 
type. 

Symptoms. — There are no special early symptoms pe- 
culiar to sarcoma differentiating it from other growths. 
Secretion is usually increased, and there is a peculiar fetid 
odor which is more pronounced after ulceration. A radiating 
pain extending to the ear, angle of the jaw, or to the tongue 
or teeth, is often present, and increased on swallowing. 
The pain usually begins quite early and is a valuable diag- 
nostic symptom. As the growth continues there is aggra- 
vation of the symptoms. Sarcoma of the tonsil is generally 
nodular and rather firm. 



Embryonic Connectivk-tissuk Tumors. 275 

DIFFERENTIAL DIAGNOSIS. 



Sarcoma. 



Generally over fifteen. 

Frequently primary. 

Very vascular; ulcerates early; 
hemorrhage profuse. 

Late involvement of cervical 
glands. 

Sometimes encapsulated. 

Sex not a factor. 



Carcinoma. 



Generally over forty. 

Seldom primary. 

Ulcerates late ; hemorrhage 
slight. 

Early involvement of cervical 
glands. 

Not encapsulated. 

Most frequent in males. 



Prognosis. — Unfavorable. 

Treatment. — Operative, if recognized early. When late, 
palliative. 

Larynx. — Seldom seen in the very young. The tumor 
originates in .the deeper structures, and although it may be 
nodular the surface is smooth. It is usually primary in the 
vocal cords, eventually implicating the other laryngeal struc- 
tures. The growth may involve all or part of the larynx, 
but seldom invades contiguous tissue. 

Symptoms. — Phonation is defective, and the respiratory 
action is interfered with early in the disease. Both symp- 
toms rapidly grow worse as the tumor increases in size. An 
irritating, hacking, spasmodic cough increases the discom- 
fort of the patient. Before ulceration begins the character 
of the secretion is practically normal, but there is an ap- 
parent increase due to the pain induced on swallowing. 
With the ulceration, the cough increases, and the secretion 
becomes mucopurulent, tenacious, and offensive. There is 
often hemorrhage, but it is more continuous than profuse. 
The growth usually does not get very large, as the distress- 
ing symptoms generally lead to an early diagnosis. The 



276 Nose, Throat and Ear. 

pain is generally intermittent and irregular, sometimes se- 
vere, but is usually more a sensation of discomfort. 

Diagnosis. — Difficult. The attempt at removal of a por- 
tion of the growth for microscopic examination is a ques- 
tionable proceeding. 

Prognosis. — Fatal. 

Treatment.- — Complete resection or extirpation of the 
larynx is the only measure which promises any relief. 

Mixed Tumors. 

Adenocarcinoma. — This is really a tubulated epitheli- 
oma, a carcinoma originating in gland tissue. 

Myxocarcinoma. — A mucoid or myxomatous degener- 
ation of any carcinoma. The term denotes the variety of 
change. 

Teratoma. — This is a congenital growth, consisting of 
the three embryonic layers. ' 

Cysts. 

The classification of cysts is by no means clear, as there 
is a diversity of opinion regarding their cause "and pathology. 

Simple or Retention Cyst. — This results from an in- 
flammatory action either within a gland duct or in the sur- 
rounding structure, which eventually lessens the caliber of 
the duct, thus interfering with the escape of the secretion, 
and gradually causes a saccular dilatation at some part of 
the duct. When complete occlusion occurs, the continued 
secretion increases the size of the cyst. After a time the 
pressure will cause degeneration and desquamation of the 
epithelial cells of the duct, and the walls are thinned by the 
same cause. Usually found after the age of twenty. This 
form is often called mucocele and is common in the nose, 
nasopharynx, and upper portion of the larynx. In the naso- 
pharynx the origin is in the adenoid tissue of the vault. 



Cysts. 277 

Seldom multiple. The symptoms are the same as myxoma. 

Treatment. — Puncture and curettement. The snare if 
pedunculated. 

Cystoma, {Hygroma, Hydroma). — This cyst may be 
found in the nose, nasopharynx, pharynx, or larynx, and is 
a dilatation of lymph vessels normally present. Most fre- 
quently seen after the age of twenty-five. Recurrence is fre- 
quent on account of the difficulty usually found in completely 
removing it. 

Dermoid. — This develops either from inclusion of a por- 
tion of the epiblastic layer within the mesoblast, or the dis- 
tention of the cavity of some persistent fetal structure which 
normally should have been obliterated. The walls of the 
cyst contain hair follicles and sebaceous glands, the secre- 
tions from the latter forming the contents of the cyst. Der- 
moid cysts are seldom found in the respiratory tract except- 
ing in the nose. When they interfere with respiration, they 
should be removed. 



CHAPTER XIII. 

DISEASES OF THE ANTERIOR NASAL 
CAVITIES. 

Septum. — (i) Malformations. (2) Deformities, (a) 
Deviation or Deflection. (1) Disease. (2) Traumatic. 
(3) Congenital. (b) Synechia. (1) Congenital. (2) 
Acquired. (3) Collapse of Abe Nasi. (4) Ulceration and 
Perforation. (Caries and Necrosis.) (5) Edema, (sub- 
mucous infiltration). (6) Abscess. (a) Acute. (b) 
Chronic. (7) Depression of Nasal. Cartilage. (8) Tu- 
mors, (a) Exostoses, Ecchondroses, Spurs, etc. (See 

Tumors, page .) (b) Blood cyst or Hematoma. 

Septum. 

Kyle's modification of Walsam's table of causes of nasal 
obstruction is given as being comprehensive and simple. 

Tabular View of Conditions Causing Nasal Obstruction. 

(a) Intranasal. 

1st. Local. — (a) Septal. — (1) Spur and erection of 
tubercle. (2) Deviation and deflection, or split septum. 
(3) Dislocation of Columnar cartilage. (4) Hematoma. 
(5) Enchondroma and osteoma. (6) Papilloma. (7) 
Vascular and erectile tumors. (8) Myxoma (polypus). 
(9) Sarcoma and carcinoma. (10) Inflammation and ab- 
scess. (11) Necrosis. (12) Local contagious ulcers (soft 
chancre). - (13) Primary syphilitic sore (hard chancre). 
(14) Gumma and periostitis. (15) Tubercle. (16) Lu- 
pus. (17) Rhinoscleroma. (17) Glanders. (19) Acti- 
nomycosis. 

278 



KxTRANASAL. 279 

(b) Turbinal. — (i) Erection of turgescence. (2) Hy- 
pertrophy (local and general). (3) Necrosis. (4) Varix. 
(5) Vascular and erectile tumors. (6) Myxoma (poly- 
pus). (7) Papilloma. (8) Sarcoma and carcinoma. (9) 
Tubercle. (10) Gumma. (11) Lupus. (12) Rhinoscle- 
roma. (13) Actinomycosis. 

(c) Accidental. — (1) Foreign body. (2) Rhinolith. 
(3) Adhesion of turbinate to septum. (4) Larvae, etc. 

2d. General. — (1) So-called hypertrophic rhinitis. 
(2). Syphilis. (3) Tubercle. (4) Lupus. (5) Rhino- 
scleroma. (6) Actinomycosis. (7) Glanders. (8) Diph- 
theria. (9) Congenital smallness. 

(b) Extranasal. 

(I) Occlusion of Anterior Narks. — (1) Congenital 
malformation. (2) Cicatricial contraction, due to — (a) In- 
jury and burns ; (b) Syphilis; (c) Tubercle; (d) Lupus. 

II. Occlusion ok Posterior Nares. — (1) Congenital 
malformation. (2) Cicatricial contraction, due to — (a) 
Syphilis; (b) Tubercle; (c) Lupus. 

III. Obstruction in the Nasopharynx. — (1) Ade- 
noid vegetations. (2) Hypertrophy of pharyngeal tonsil. 

(3) Growths from the vault (nasopharyngeal polypus). 

(4) Retropharyngeal abscess. (5) Adhesion of soft palate 
to pharyngeal wall. (6) Retropharyngeal adenoma. (7) 
Retropharyngeal sarcoma. (8) Enlargement of the tonsils 
(adenoma). (9) Tumors of the soft palate. (10) Menin- 
gocele and encephalocele. (11) Growth from sphenoid 
sinuses. (12) Enchondroma of Eustachian tube. 

(IV) Obstruction due to Extension of Growths 
from Neighboring Cavities. — (1) Fibrous, osseous, sar- 
comatous, and carcinomatous tumors of the antrum. (2) 
Growths from the ethmoidal, sphenoidal, and frontal sin- 
uses. 



280 Nose, Throat and Ear. 

Symptoms, Signs, and Effects of Nasal Obstruc- 
tion. — The most prominent symptoms of nasal obstruction 
are: (a) Inability to breathe freely through the nose; (b) 
Alteration in the voice ; (c) Characteristic facial expression ; 
(d) The presence of a discharge from the nose, or at the 
back of the throat. 

(i) Swelling or redness of the external nose. (2) In- 
tolerable itching in the nostril. (3) Headache. (4) Ver- 
tigo- (5) Aprosexia. (6) Impaired general health. (7) 
Defective development. (8) Deformity of the chest. (9) 
Hypochondriasis and melancholia. (10) Shallow breath- 
ing. (11) Elongation of uvula. (12) Spasmodic cough 
and asthma. (13) Aphonia. (14) Night sweats. ■ (15) 
Nightmare and distressing dreams. (16) Snoring. (17) 
Constant and oft-recurring catarrh of the pharynx, larynx, 
trachea, and bronchi. (18) Restlessness, twitching, and 
even convulsions in young patients. (19) Sneezing. (20) 
Perversion of the senses of smell and taste. (21) Sensation 
as of a movable body in the nose. (22) Deafness. (23) 
Salivation. (24) Eye-affections. * (25) Hernia. (26) 
Stammering and stuttering, nocturnal enuresis, epilepsy, 
chorea, dyspepsia, gastralgia, palpitation of the heart, and 
muscular rheumatism. 

The causes of nasal obstruction may be conveniently 
classified under the following heads : 

1. The intranasal, or those depending on some primary 
condition in the nose itself. 

2. The extranasal, or those depending on some condition 
external to the nose. 

The intranasal may be subdivided into local and general. 

I. The local causes are due to lesions limited to the sep- 
tum, turbinates, or other parts of the nasal chambers ; to 
accidental conditions, as the presence of a foreign body or 
rhinolith ; and to adhesions between the turbinates and sep- 
tum. 



Deformities of the Septum. 2S1 

2. The general intranasal causes are such as depend on 
a general swelling of the mucous membrane, due to catarrh 
or to such affections as syphilis, tuberculosis, rhinoscle- 
roma, etc. 

The extranasal causes may be subdivided into the fol- 
lowing classes : 

1. Occlusion of the anterior nares, due to congenital mal- 
formation, or cicatricial contraction following an injury or 
such diseases as syphilis or lupus. 

2. Occlusion of the posterior nares, which may also be 
the result of congenital malformation or of cicatricial con- 
traction. 

3. Obstruction in the nasopharynx, due to adenoid vege- 
tations ; polypi, or growths ; enlargement of the faucial ton- 
sils ; adhesion of the soft palate to the postpharyngeal wall ; 
tumors of the soft palate; meningocele and encephalocele. 

4. Obstruction caused by extension of growths from 
neighboring cavities, such as the antrum or the ethmoidal or 
frontal sinuses. 

I. Malformations of the Septum. 

Under this heading all congenital conditions are in- 
cluded. It may be a deflection, deviation, or deformity. As 
a rule the cartilaginous portion only is affected. When 
there is only a partial, development of this portion there may 
be an opening between the two nasal cavities, which re- 
sembles a perforation from disease. Any of the dimensions 
of the cartilage may be deficient. Congenital anomalies of 
the septum are associated with irregular development of the 
palatal or facial bones. 

2. Deformities of the Septum. 

In the ideal nose the septum is perpendicular to the nasal 
floor, and divides the space into two equal cavities. This 



282 



Nose, Throat and Ear. 



condition is seldom if ever found, the nasal passages being 
asymetrical, usually through variation of the septum. In 
adult life this may be more marked than in childhood. In- 
flammatory changes also have a tendency to increase the 
deviation. Each case presents its characteristic changes. 
The septal curvature may be horizontal or perpendicular. 




7 » 9 

Fig. 64. Deflections of the septum : 1. Redundant tissue, cod - 
cave ; 2. redundant tissue or spur ; 3. redundant tissue at floor ; 4. S 
deflection ; 5. simple deflection to the left ; 6. lines of cuts for cor- 
recting 1 and 11 ; 7 and 8, method of correcting 9'; 10. split cartilag- 
inous septum. {After Kyle.) 



The different curvatures will usually come under the classi- 
fication shown in Fig. No. 64. 

1. Deviation or Deflection from Disease. — This may 
be a primary or secondary condition. Any inflammatory 
action of the septal mucous membrane or perichondrium 
may result in deviation or deformity. Superficial ulceration 
of the mucous membrane of . the septum, the result of 
abrasions or of eruptive disease, may be followed by devi- 



Deformities of the Septum. 283 

ation of this structure. Hypertrophied turbinates, or tumors 
in the nasal cavity, may, through pressure, be an exciting 
cause. The unrecognized presence of a foreign body may 
also be a factor in producing this condition. Syphilis, 
lupus, or tuberculosis may also cause deflection. 

2. Traumatic Deflection. — This condition occurs 
most frequently in childhood, although often not recognized 
until later in life. Children when quite young are especially 
liable to injuries involving the nose, but usually no attention 
is paid to the condition, which later often results in a 
marked deformity of the septum. The bony portion is 
nearly always affected in these cases. The deformity may 
not be perceptible externally, but as a rule it shows, and 
the direction of the blow, as well as its force, will be ap- 
parent by the amount of deflection. In some instances, the 
resulting deformity of a traumatism may require extensive 
surgical measures, especially when the bony framework is 
injured. Often a traumatic deflection occurs just within 
the nasal orifices. This is due to dislocation of the anterior 
end of the septum from the columnar cartilage. In these 
cases there is usually considerable obstruction to nasal 
respiration. Inspection will show the cartilage just within 
one of the anterior nares, extending to the muco-cutaneous 
surface. It is prominent, smooth, and covered with thin 
mucous membrane, usually slightly inflamed. The opposite 
nostril will show a slight depression corresponding to the 
prominence. Usually the result of ah injury, but may be 
due to disease or irregular development. The tip of the 
nose is usually somewhat deformed. A slight dislocation 
is very frequent, and seldom requires surgical treatment, 
unless there is also considerable deviation of the cartilagi- 
nous or bony portions of the septum to interfere with normal 
respiration. When the cartilage is split and with but slight 
depression on the opposite side, the obstructing portion 
should be removed. When the opposite side is intact, there 



284 Nose, Throat and Bar. 

will be no danger of the tip of the nose drooping. The 
mucous membrane should be dissected from the prominent 
surface, the cartilage removed with knife or gouge, and the 
flap allowed to drop into position. Healing rapidly ensues. 

3. Congenital Deflection. — It is probably true that 
many of the cases of so-called congenital deformity of the 
nasal structures are the result of pressure during partu- 
rition. The body structures are soft, almost cartilaginous, 
and it is an acknowledged fact that manipulation of the 
nose in early infancy will modify its shape. Unimpeded 
nasal respiration also has a marked influence on the regular 
development of the nasal fossae, the superior arch and the 
symmetry of the facial bones. When there is a deficiency 
of respiratory nasal space prior to the age of seven, the bony 
and cartilaginous structures become so firm that compara- 
tively little can be done to remedy the defect. 

Treatment. — No set rules can be laid down for treat- 
ment in these cases. Practically all operations are modi- 
fications of Adam's method. Each case must be studied 
according to its individual merits. A general line only 
of procedure can be given. When only the cartilage is de- 
flected, and it is thin and flexible so that it can be readily 
pushed to the normal position by inserting the finger into 
the nostril, the desired result can be obtained by using 
a malleable tube or splint. This is molded to fit the de- 
flected surface, and by gradually expanding the tube the 
desired amount of pressure can be obtained. This pressure 
induces a slow inflammatory process which eventually 
strengthens the cartilage and retains it in its normal po- 
sition. The tube should be worn for four to twelve hours 
each day for two or three weeks. Care should always be 
exercised that too much pressure is not produced, on ac- 
count of the danger of starting an ulcerative process. 

In deflection of the septum, where it is not sufficient 
to interfere with free respiration, operative measures are 



Deformities of the Septum. 285 

usually unnecessary. In surgical cases, if the deflection is 
confined to the cartilage, the curvature being comparatively 
regular, and no especial thickening of tissue, it is not neces- 
sary to remove any of the tissue. If the curvature extends 
close to the floor of the nose, an incision should be made on 
the concaved surface close to the lower portion dividing 
the mucous membrane and perichondrium. Then with the 
nasal saw cut nearly two-thirds through the cartilage. It 
is not necessary to make this incision when the curvature 
does not reach the nasal floor, the cartilaginous septum 
being fractured by a rolling motion of the forceps, so the 
septum may be restored to the desired position. By the 
use of the nasal tubes, the septum is retained in place. 
Should there be much swelling of the tissues within twenty- 
four or forty-eight hours, the tubes should be removed 
until the swelling subsides. When there is but little swell- 
ing and edema, the tubes may be left in position. The 
pressure can easily be regulated. During the time the 
tubes are worn, the nostrils should be flushed occasionally 
to get rid of excess of secretion. A solution of 10 gr. 
boric acid to an ounce of warm water is best. The tube 
may be removed daily for the purpose of cleansing if the 
tissues are much swollen, and be left out for several hours. 
As a rule I have not found this necessary. When the bony 
portion of the septum is also deviated, it is necessary to 
extend the field of operation, sawing through the bony 
portion to about the same depth as the cartilaginous sep- 
tum, making two cuts, in order to control the line of frac- 
ture, then the septum is crushed with the forceps. The cut 
should always be deep enough to make it comparatively 
easy to fracture the bony partition. The tissue is kept in 
position by the means already described. When the de- 
flection is vertical or V-shaped, two vertical incisions two- 
thirds of the perpendicular length and dividing the deflec- 
tion into equal parts, are necessary before crushing. The 



286 



Nose, Throat and Ear. 



same after treatment should be used as in the other vari- 
eties. Enlarged turbinates are often present in the nasal 
cavity corresponding to the concave surface, and their re- 
duction or partial removal will be necessary. 





Fig. 66. Sharp 
bulging of septum 
on one side only. 



Fig. 65. Lateral deflection involving both bony and cartilag- 
inous septum, showing lines for saw cuts to control the fracture in 
straightenining. (About % natural size. After Kyle) 

In some cases of deflection, there appears to have been 
a splitting of the two halves (Fig. 66), one side only bulg- 
ing, the other side being almost perpendicular. The bulg- 
ing is acute, and there is considerable thickening of the 




Kyle's Saws. 

apex. In such cases a semi-circular incision is made on 
the under side, the mucous membrane dissected upward, 
and the projection sawed off. The operation should be 
made in such a way that no injury is done to the mucous 



Deformities of the Septum. 



287 



membrane on the unaffected side, as this will increase the 
danger of ulceration or perforation. When there is re- 
dundant tissue as well as deviation of the septum, the ex- 
cess of tissue must be removed to make the operation suc- 
cessful. When the defect is of the cartilaginous portion, 
the mucous membrane should be- dissected upward from 
the lower portion of the curvature, and a sufficient amount 
of cartilage removed, the section being V-shaped. This 




Fig. 67. The V-shaped cuts are dagrammatic. The position 
and direction vary according to the case.' The dotted line indicates 
the position of cut on opposite side. {After Kyle) 

may be done with a saw or knife. The incisions should 
be made so as not to injure the mucous membrane .on the 
opposite side. The V-shaped incisions, the number de- 
pending upon the amount of deflection, will give the best 
results, as when the septum is pushed to the normal po- 
sition there will not be the tendency to a return to the ab- 
normal position, through pressure. This operation of 
Kyle's has given the best results of any so far devised. 
When properly performed no support is required, and 
usually the less washing of the cavity, the better the results. 



288 



Nose, Throat and Ear. 



There are numerous operations devised for correcting 
deviations, and all have their good points, but the operator 
must use his own judgment in each case. The Asch oper- 
ation is probably used in the greatest number of cases. The 
cuts made with the Asch forceps are as nearly at right 
angles to each other as possible, and through the point of 
greatest deviation, then the crushing forceps are used to 
destroy the resiliency of the deflected portion. The parts 
are held in position by the nasal tubes. 

Synechia. — This is generally a bony, cartilaginous, or 







70 

Fig. 68. Septal deviation and prominent spur in a case of hyper- 
trophic rhinitis. Fig. 69. Deflection of septum with osseous en- 
largement associated with enlargement of the turbinate tissue. Fig. 
70. Same as 69, after the application of cocaine, which constricts the 
soft tissue. 



fibrous band extending from the septum to the lateral nasal 
wall. A synechia may extend from one turbinate to an- 
other. The condition may be either acquired or congenital. 
Acquired. — In this form there must be erosion of the 
mucous surfaces. The two surfaces are usually in contact 
with each other, but occasionally a fibrous band may be 
found through the uniting of the plastic material from the 
ulcerated surfaces, building up until they meet. The con- 
ditions requisite to form a synechia may be brought about 
in various ways, such as the irritation of foreign bodies, 
simple chronic or hyperplastic rhinitis producing ulceration 



Collapse of the Ai^E. 289 

through pressure of the surfaces, or by surgical measures, 
or the use of escharotics. The interference to nasal respi- 
ration will produce a line of symptoms not differing from 
any other obstruction in the nasal cavities. 

Congenital. — The usual location is between the middle 
turbinate and the septum. The synechia is usually carti- 
laginous or bony. 

Treatment. — Removal of the band should be insisted 
upon. The operation should be so done that there will be 
as little injury of the surrounding tissues as possible. 
Usually the less interference with the nasal cavity after the 
operation, the better. If exuberant granulations occur, the 
use of salicylic acid ointment is generally all that is nec- 
essary. 

3. Collapse of the Alae. 

Collapse of the alae or narrowing of the nostrils may re- 
sult from non-development of the lateral cartilages or by 
lack of development through interference with nasal respi- 
ration in infancy. When there is obstruction of nasal 
respiration, the dilator muscles of the alae become weakened 
through lack of use, and collapse. In long, pointed noses, 
having narrow, slit-like nasal orifices, the constrictor 
muscles may increase the narrowing. Whenever there is 
collapse or excessive narrowing of the nostrils, mouth 
breathing follows, and various affections of the pharynx 
and larynx result. 

Treatment. — In some cases, especially when the narrow- 
ing is due to the action of the constrictor muscles, a short, 
perforated silver tube, made especially for the case, and 
fitted within the nostril, not extending to the bony portion 
of the septum, may improve the condition. The tube should 
be worn at night, or not over fifteen hours at a time. The 
tube can be easily changed in contour as required, and by 
persisting in its use for a number of months many cases 
are benefited. When the narrowing is due to faulty devel- 

IQ 



290 Nose, Throat and Ear. 

opment of the lateral cartilages, little can be done. In some 
cases, however, the use of the tubes will improve the con- 
dition. 

4. Ulceration and Perforation (Caries and Necrosis). 

Ulceration. — Ulceration and perforation of the nasal 
septum are often associated. Ulceration may exist without 
perforation, but peff oration seldom occurs without a pre- 
ceding ulceration, the exceptions being the result of trau- 
matism, or congenital. 

Ulceration may be caused by external conditions, as 
dust or irritating vapors acting as mechanical irritants. 
Vascular changes from any cause may result in ulceration. 
As a result of vascular changes, there may be an itching or 
irritation, which will induce the patient to pick the septal 
region, thus producing an area for ulceration. In deflec- 
tions of the septum, particularly where it is an acute angu- 
lar deviation, ulceration is liable to occur on the concave 
surface. This results from the vascular changes as well 
as from irritation due to accumulation of foreign material. 
Intestinal obstruction or irritation, menstrual derangements, 
and in several cases under observation prostatic irritation, 
produced a tendency to engorgement of the nasal mucosa, 
causing a desire to pick the nose. 

A foreign body or a growth in the nose may cause ulcer- 
ation, either through irritation or pressure against the mu- 
cosa. Lesions of the cartilage, or perichondritis from an 
acute infectious fever or specific inflammatory condition 
affecting the mucous tissue, may be a cause. In these cases 
the lesion is secondary, the destructive process commencing 
in the deeper tissues and progressing toward the surface, 
being a reversal of the usual ulcerative process. Ulcer- 
ation of the mucous membrane may follow in any systemic 
disease when there is lowered vitality. 

In syphilitic ulceration there is nearly always bony ne- 



Ulceration and Perforation. 291 

crosis also. Irritating vapors, the use of the actual or gal- 
vano-cautery, or of escharotics, may cause ulceration. 
While ulceration may occur at any period of life, it is less 
frequent in the very young or aged. When found in infants 
or the very young, inherited syphilis should be suspected. 

Location. — Usually on the mucous membrane covering 
the cartilaginous septum, but when due to specific or infec- 
tious disease, the membrane covering the bony portion may 
also be affected. The ulceration is usually located in the 
upper two-thirds of the septum, but the position is also de- 
pendent upon the cause. The size varies from a pin-head 
to almost the entire mucous surface. One side of the sep- 
tum only is usually affected, and when occurring on both 
sides it is not necessarily opposite. The character of the 
discharge varies. In specific ulcers, or those resulting from 
foreign bodies, there is an offensive odor. In other ulcers 
the odor is slight, if any. The amount of the discharge de- 
pends largely upon the extent of the ulcerative surface. 

Treatment. — In ulceration of the septum, if seen early, 
the destructive process can usually be arrested without per- 
foration. The difficulty in too many cases is over-anxiety 
to do something, and the ulcerative surface is irritated and 
made worse by frequent local applications. The policy of 
letting the surfaces severely alone, excepting when some 
unirritating wash is necessary for cleansing purposes, will 
result in more cures than the diligent application of oint- 
ments, powders, etc. The internal administration of potas- 
sium bichromate 1/100 gr. will effect a cure in the major- 
ity of cases. If the ulceration is specific, the application of 
thuja in glycerine or Lloyd's hydrastis will aid the healing 
process, but systemic treatment must be used. Potassium 
iodide in full doses in acquired syphilis ; in the hereditary 
form, gold and sodium chloride. Potassium bichromate 
may be used in connection with the above treatment. When 
there is an edematous condition of the tissue surrounding 
the ulcer, the salicylic acid wash will be beneficial, but must 



29 2 Nose, Throat and Ear. 

not be used too frequently. The mucous membrane of the 
nasal cavities is not intended for any form of heroic local 
treatment. 

Perforation OF the S^ptum. — Perforation of the car- 
tilage occurs in about one-half of one per cent of cases. 
Congenital defects are rare. Occupation appears to be a 
prominent factor. When the vocation is such as exposes 
the person to irritants, the cases of perforation are more 
frequent. Usually the perforation is the result of picking 
the nose to relieve the irritation caused by the vapors or 
dust in which one is working. Necrosis of the cartilage is 
often found in syphilitic and tubercular inflammatory pro- 
cesses. It sometimes also follows eruptive or infectious 
fevers. Injuries also may be factors in perforation, through 
the employment of escharotics or cauteries. In many cases 
the patient is unaware of an existing perforation until an 
examination by a physician reveals the fact. The shape and 
size of the perforation is influenced largely by the cause 
and location. When in the cartilaginous portion, it is usu- 
ally round or oval, but is usually irregular if in the bony 
portion, when it generally is of syphilitic origin. Usually 
the perforation is single, but may be multiple. In congen- 
ital perforation there is usually asymmetry of some of the 
facial bones, and an absence of inflammatory action. A 
septal abscess when it ruptures spontaneously, frequently 
caijises necrosis of the cartilage, and perforation. Perfora- 
tion may also result from a malignant growth, as carci- 
noma. Perforations may be divided into four general 
classes : 

(i) Faulty Develop ment. (2) Localized Inflam- 
matory Conditions. (3) Injury. (4) A Local Mani- 
festation of some Constitutional Condition. 

Sex. — This does not seem to be a factor. Vocation, 
nasal deformities, and constitutional disorders are the prin- 
cipal causes. 

Age. — Usually between twenty and forty, although they 



Ulceration and Perforation. 293 

may occur at any age. The ulceration leading to a perfora- 
tion is generally unilateral. When the necrosis is on both 
sides, the perforation usually results from a systemic in- 
fection. 

Pathology. — Practically the same as necrosis of tissue 
in other regions. 

Symptoms. — There are no symptoms peculiar to this 
condition, the discovery being made either accidentally or 
during an examination. When a perforation has occurred, 
it is very seldom anything can be done to close it, treatment 
being directed to preventing more destruction of tissue. 

Treatment. — When due to occupation, and it is im- 
practicable for the patient to abandon the work, the use. of 
a mask would in many cases prevent an increase of the 
ulceration, but there are few who will use such appliances. 
Plugging the nostrils with a small piece of sponge or cotton 
wool will often be of use. The advice often given to 
cleanse the nasal cavities frequently with an alkaline solu- 
tion is of doubtful utility, excepting among those working 
in acid fumes. In some cases it may be necessary to touch 
the edges of the perforation at bleeding or ulcerative points 
with some strongly astringent preparation, or a 50 per cent 
solution of silver nitrate. When of syphilitic origin, po- 
tassium iodide should be given until the physiological ef- 
fects are obtained. When the bony structures are also 
affected, the gold and sodium chloride will be found valu- 
able. This drug should also be pushed to its full effects. 
Perforation, the 'result of tubercular disease, shows a dis- 
position to invade the surrounding tissues. In these cases 
Fowler's solution and phytolaccca should be given, as there 
is a probability of spreading by lymphatic invasion. 

5. Edema (Submucous infiltration.) 

Edema of the septal mucous membrane may occur at 
any stage. External irritants coming in contact with the 



294 Nose, Throat and Ear. 

mucous surface; injuries of not enough force to fracture 
the bones or cartilage, or associated with a perichondritis 
may cause it; edema may be found in specific inflammatory 
conditions, or involvement of the cartilage following ty- 
phoid or infectious fevers. Edema may be unilateral or 
bilateral, more often the latter. Edema is not infrequent 
after perative procedures, especially the cautery or escha- 
rotics. It may also result from affections of the teeth. 

Treatment. — Often absorption occurs without any treat- 
ment. When it is sufficient to cause obstruction of nasal 
respiration, puncture may be required. The local applica- 
tion of a cotton tampon saturated with glycerin yrill often 
cause a rapid reduction of the swelling. The use of sali- 
cylic acid ointment on cotton tampons will also afford re- 
lief. Internally the use of apis and apocynum will usually 
rapidly relieve the condition. 

6. Abscess. 

Acute Abscess. 

Etiology. — An acute abscess of the septum may follow 
a traumatism, either direct or through effusion of blood 
into the tissue, the result of a blow. It may also follow 
the infectious fevers, and has been noticed in erysipelas 
and the so-called uric acid diathesis. An acute abscess may 
result from an acute coryza, or may be associated with 
purulent rhinitis in children, or in scrofulous or rachitic 
persons. In dental disease it is sometimes present, espe- 
cially when the superior maxillary bones are malformed. 

Pathology. — Similar to abscess formation elsewhere. 

Symptoms. — When the result of traumatism, there are 
signs of external injury, as well as the history. Swollen 
and edematous mucous membrane, often occluding both 
nostrils, will be found. The external surface of the nose 
is swollen and reddened. Frontal headache; conjunctiva 
of the eyeballs congested and the lids more or less edema- 



Abscess. 295 

tous. Severe throbbing, lancinating pain in nose. General 
malaise, and often increased temperature. In from twenty- 
four to forty-eight hours a distinct pointing can usually be 
observed; the discoloration is more pronounced, and the 
pain less severe. The swelling may involve the entire face, 
or only the upper lip. The nose is extremely sensitive to 
pressure. As the abscess progresses, fluctuation will be 
found on palpation. 

Diagnosis. — Usually easy ; but an acute edema may be 
mistaken for this condition; however the symptoms are less 
marked, with the exception of the swelling. 

Prognosis. — Favorable, if recognized early and a free 
incision is made. When allowed to rupture spontaneously 
there may result either deformity or perforation. 

Treatment. — A free incision through one side of the 
cartilage, at a point low enough to insure drainage, should 
be made as soon as the disease is recognized. As there is 
a tendency to early closure of the incision, free drainage 
may be maintained by introducing a strip of gauze in the 
opening, or by making the incision obliquely through the 
cartilage. After opening the abscess, the cavity should be 
thoroughly cleansed. Internally the administration of gold 
and sodium chloride, silicea, or calcium sulphide. If a 
rheumatic or gouty diathesis is present, the use of rhus 
tox., bryonia, cimicifuga, or rhamnus Californica may be 
required. Colchium is of value in the gouty form, but care 
should be observed not to give it in doses that will derange 
the bowels, a result often following the use of this drug. 

Chronic Abscess. — Seldom seen. It sometimes follows 
typhoid or other fevers, where the cartilage becomes in- 
volved, or as the result of syphilitic or tubercular necrosis. 
Perforation, however, usually follows the latter affections. 
As a rule chronic abscess invades the anterior portion of 
the cartilaginous septum, the development is slow, and the 
symptoms not marked. Examination reveals a fluctuating 



296 Nose, Throat and Ear. 

tumor of the septum, which partly obstructs the fossae. 
When of syphilitic or tubercular origin, the history will aid 
in the diagnosis. 

Treatment. — A free incision should be made on one 
side, the limiting membrane thoroughly curetted, and the 
cavity well washed. In some cases it will be best to pack 
the cavity with gauze after the flushing. There is in these 
cases a tendency to perforation. Internally the use of lime, 
gold and sodium chloride, etc. Hygienic and medicinal 
measures to improve the general nutrition should be em- 
ployed. 

7. Depression of Nasal Cartilage. 

When there is depression of the cartilage, various ex- 
ternal deformities of the nose result. Trauma or abscess 
of the septum may be the cause of the depression. Ulcer- 
ation and perforation of the septum may be associated with 
this condition. Depression of the cartilage may take place 
without destruction of tissue, or there may be more or less 
loss of structure. A depression, the result of septal per- 
foration, will usually be flat, the soft structures appearing 
to be spread out on the face. The nasal orifice is increased 
laterally and diminished perpendicularly. Depression, the 
result of an injury or septal abscess has a sunken appear- 
ance on the top of the nose, and tip tilted up. 

Treatment. — Each case must be treated according to the 
character of the deformity. 

Tumors. — Bony growths have been considered. 

Hematoma of the Septum (Blood-cyst). 

Hematoma is a sudden effusion of blood into the sub- 
mucosa caused by an injury. The effusion may be bilateral 
or unilateral, involving part or all of the septum. Fracture 
of the bone or cartilage may also be present. There is a 
history of injury, sudden appearance and secondary in- 



Hematoma of the Septum. 



297 



flammation. The effused blood may become encysted or 
may break down and suppurate through secondary inflam- 
mation. Small hematoma may result from the rupture of 
a blood vessel, as sometimes happens in the exanthemata, 
or on violent exertion. These cysts are usually soon ab- 
sorbed and treatment is not required. In extensive effu- 
sion it is nearly always necessary to incise. After evacu- 
ation of the blood, the nasal cavity should be packed with 
gauze, so that pressure over the location of the hematoma 
is exerted. The gauze should be changed every twenty- 
four hours, and should not be packed so tightly as to cause 
ulceration 




A* WOOHBR & SON. 3lN., O- 



Asch Nasal Set. 



CHAPTER XIV. 

DISEASES OF THE ANTERIOR 
NASAL CAVITIES. 



DISEASES OF THE ACCESSORY SINUSES. 

Diseases of the Maxillary Sinus*. — (a) Catarrhal 
Inflammations. (i) Acute. (2) Chronic. (b) Ozena, 
(c) Empyema. (1) Acute Purulent Inflammation. (2) 
Chronic Purulent Inflammation. (3) Confined Suppura- 
tion, (d) Specific Inflammations, (e) Acute Infectious 
Diseases. (f) Emphysema. (g) Foreign Bodies. (h) 
Mucocele, (i) Tumors, (j) Phlegmonous Inflammation. 

Very little is known of the functions of the accessory 
sinuses, and the majority of diseases affecting these cavities 
are not well understood. 

Catarrhal . Inflammations. 

Acute Catarrhal Inflammation. — This may occur 
wjth any acute rhinitis, being simply an extension of the 
inflammatory process. The cause of the rhinitis will have 
considerable influence on the antral condition. Carious 
teeth or disease of the alveolar process may in some in- 
stances cause antral disease through continuity of tissue. 
It has also been found following intranasal operations, 
especially cauterization ; the insufflation of powder or con- 
siderable pressure in the use of the douche. The method 
of plugging both the anterior and posterior nares in epis- 
taxis ; the employment of hydrogen dioxide in the nasal 
cavity may, by causing extraneous material to be forced 

298 



Catarrhal Inflammations. 299 

into the antrum, excite an acute inflammatory process. It 
Jias also been traced to the entrance of secretions from the 
frontal or ethmoidal sinuses through the antral opening. 
The disease is sometimes found following a traumatism, or 
coexistent with nasal manifestations of the exanthemata, 
or a part of a general manifestation of cardiac or renal 
disease. Tumors, teeth, etc., in the cavity have been found 
to be causes of the disease. Systemic poisoning has also 
produced it. 

Symptoms. — As a rule the pain is not severe, but is 
deep-seated. Pressure against the upper teeth on the af- 
fected side may cause a sensation of tenderness. There 
may also be more or less constant dull pain along the teeth 
of the affected side, and also infraorbital or intraorbital 
pain. Edema of the mucosa on the antral side may be 
present. 

Diagnosis. — Not always easy, excepting in typical cases. 

Prognosis. — Usually favorable. 

Treatment. — The inflammatory process is identically 
the same as of mucous membrane elsewhere. The majority 
of writers insist that treatment is not of the same value 
here as in more open cavities, but this has not been true in 
the majority of cases. In some instances it is true the 
antral opening will become closed, so that an artificial open- 
ing into the antrum will be required. In such cases the 
point which will afford the best drainage should be selected. 
The contour of the antrum must be considered. The canine 
fossa may be the point of selection, or the opening may be 
made through the nasal cavity, using a curved trocar and 
canula. 

Local. — Douches should be avoided as a rule. In many 
cases where there is edema of the tissues the use of either 
cotton tampons saturated with glycerin, or covered with 
salicylic acid ointment will relieve the occlusion, free drain- 
age resulting. 



$66 Nose, Throat and Ear. 

Internally in the early stage, aconite. Gelsemium, by 
rendering the secretion more fluid will usually be indicated. 
Phytolacca, potassium bichromate, lime, silicea, or hama- 
melis may be required. After the acute symptoms subside, 
hydrastis in combination with phytolacca is nearly always 
indicated. 

The use of powerful constringing solutions, while giv- 
ing relief temporarily, will cause relaxation of the tissues 
and complications later on. 

Chronic Catarrhal Inflammation. — This condition 
is frequently the result of repeated acute attacks, or from 
an acute inflammation where the exciting cause is constant. 
As a rule, suppuration occurs in these cases, but at times 
the disease is simply that of a chronic catarrhal inflamma- 
tion. If the disease is unchecked the antral opening may 
become closed, and the secretions being retained, the term 
hydrops antri might be used. 

In some cases there may be a low-grade cell prolifer- 
ation from the mucous membrane, forming myxomatous 
masses and filling the cavity with a soft, translucent mate- 
rial, which is the condition termed mucocele. The path- 
ological changes are similar to inflammatory changes of 
any mucous membrane. 

Symptoms. — These vary considerably, but are influ- 
enced very much by the patency of the ostium maxillare. 
Usually there is a sense of slight irritation or a dull ache 
in the sinus. At intervals there will be a discharge of secre- 
tion into the nasal cavity of the affected side. This secre- 
tion may be a clear, glairy, tenacious, mucous material, or 
may partake of any of the characteristics of mucous mem- 
brane secretion. After the escape of this secretion there 
is a sense of relief on the affected side. 

On inspection the secretion can often be seen oozing 
from the antral opening, filling the middle meatus. This 
may be more marked if the excess is wiped away, and the 



Catarrhal Inflammations. 301 

head inclined sideways to assist gravity in emptying the 
antrum. 

When the antral opening is closed, preventing the es- 
cape of the secretion, there will ensue a severe line of symp- 
toms : gradual distention of the antrum results, the thin 
walls allowing swelling in all directions ; the eyes become 
congested and prominent ; the cheek swollen and teeth sore. 
The pain gradually increases until relieved by the exit of 
the secretion either by natural or operative methods. 

Diagnosis. — Often difficult on account of nasal con- 
ditions which mask the antral disease". 

Prognosis. — Guarded, as a. cure depends upon so many 
influences. 

Treatment. — The infected form of this disease is most 
often seen, although occasionally a non-infected case pre- 
sents. In these cases an opening into the antrum is re- 
quired, and curettement of the antral surface whenever 
pressure symptoms are prominent. Systemic measures will 
frequently obviate the necessity for surgical treatment. 
Internally, calcium, silicea, gold and sodium chloride, po- 
tassium iodide. The same general line of treatment given 
under acute catarrhal inflammation will be required. 

Ozena of the Antrum. — This may be independent of, 
or accompany, ozena of the nasal cavities. The causes and 
pathology are probably identical with the nasal form. 
There are no characteristic symptoms of the disease in this 
location, but this condition may possibly account for the 
foul odor where no nasal manifestations are present. 

Diagnosis. — Difficult. 

Prognosis. — Guarded. 

Treatment. — If the cause can be determined, the re- 
moval of the exciting* factor will be necessary. As a rule, 
the treatment will not vary essentially from the chronic 
catarrhal type. The use of potassium bichromate in these 
cases will have a tendencv to relieve the crust formation. 



302 Nose, Throat and Ear. 

Empyema of the Antrum. 

Acute: Purulent Inflammation. — Empyema is usu- 
ally the result of a catarrhal inflammation, which becomes 
purulent in character. A general debilitated condition of 
the system is often present. The claim is made by some 
that the abuse of certain drugs, especially mercury, is a 
factor in some instances. Disease or division of the fifth 
nerve has been given as an incidental factor. The infec- 
tious diseases, la grippe, traumatisms, and diseases of the 
teeth or alveolar process, the latter especially, are important 
causes of this disease. Children are usually exempt on 
account of the lack of development of the antra prior to 
puberty. 

Symptoms.- — Usually marked. A profuse discharge of 
pus from the nostril of the affected side ; this may be con- 
stant but usually appears suddenly, with marked intervals 
of freedom from the discharge. The material, as a rule, 
is yellowish, sometimes streaked with blood, and may have 
a slight, or very offensive odor. The exit of pus is often 
facilitated by inclining the head sideways, downward, and 
forward. Pain will depend upon the ease w T ith which the 
secretion escapes from the antrum. When present, is usu- 
ally described as dull and heavy, and there is nearly always 
inability to locate the site definitely. Percussion of the 
teeth or cheek may reveal tenderness. At times there may 
be a small fistula at the point where a tooth has been ex- 
tracted, and pus may be found in the opening. "Occasion- 
ally there are systemic disturbances, as a chill, headache, 
etc. 

Diagnosis. — Anterior rhinoscopy may reveal pus in the 
middle meatus of the affected side. 'This should be care- 
fully wiped away, and the head then inclined obliquely 
downward and forward, the affected side upward, when if 
pus is again found in this location, it will be good evidence 



Empyema of The Antrum. 303 

of antral disease. The possibility of empyema of the other 
accessory sinuses must be remembered. The more or less 
constant return of pus and the sensation of discomfort or 
pain in the antral region tend to confirm the diagnosis. 
The use of the diagnostic lamp for transillumination of the 
structures, while of value in some cases, is not positive evi- 
dence of pus in the antrum, as there are many conditions 
which may obstruct the passage of light, as asymmetry of 
the antra, external swelling, or discoloration. 

Prognosis. — Guarded. The disease may rapidly subside, 
or may merge into a stubborn chronic condition. 

Treatment. — Similar to that for the catarrhal form. 

Chronic Purulent Inflammation. — The causes of 
this form are practically the same as of the acute type, or it 
may result from the acute type. The pathology is similar to 
chronic suppuration of the mucous membrane generally. 

Symptoms. — These depend upon whether there is a free 
exit for the pus, or whether it is retained within the antrum. 
In the former case, the symptoms are similar to those of 
the acute type. There is, however, usually more discharge 
from the affected side, the secretion often being bright 
yellow and with more or less fetor. During sleep the puru- 
lent material may pass back through the posterior nares 
into the pharynx. A hacking cough is often present, re- 
sulting from the dripping of the discharge from the pos- 
terior nares. Mental depression is often present, the patient 
imagining those around can detect the offensive odor. This 
is unusual, as the odor is not often marked. There may be 
an acrid, bitter, or mawkish sweet taste resulting from the 
discharge, and gastric disturbances are not infrequent as a 
result of swallowing, some of the purulent material. The 
general health is often affected. 

Diagnosis. — The symptoms given, and a careful exami- 
nation similar to that of the acute type. 



304 Nose, Throat and Bar. 

Prognosis. — Time and steady treatment are necessary 
for a cure, but the disease is a difficult one to treat, al- 
though it is seldom, if ever, fatal. 

Confined Suppuration. — In this type the pus is re- 
tained within the antrum, not finding a natural means of 
egress. This condition usually results from an occlusion 
of the antral opening, which may be closed prior to the 
acute suppurative process, or be occluded by the inflam- 
matory or other morbid conditions. In some few cases the 
occlusion may be congenital. A turgescent condition of 
the nasal mucosa through an acute catarrhal condition, or 
coexistent with the exanthemata, may be a cause. Polypi 
or the presence of a foreign body may also be a cause. 
As a rule, the disease is slow in development. The antral 
region becomes tender on pressure, especially pressure on 
the teeth. A dull headache may be present and also a sen- 
sation of fullness and heaviness of the superior maxillary. 
The pain becomes aggravated, and there may be throbbing 
and beating, with supra-orbital, infra-orbital, or root of 
the nose, aching. Swelling of the antral walls may become 
excessive". There may be stenosis of the nasal space on the 
affected side, the hard palate bulging, and sometimes spon- 
taneous rupture through this structure. Swelling of the 
cheek, exophthalmos, conjunctival congestion, impaired 
vision, and excessive lacrimation may occur. The tissues 
over the antrum are hot. to touch, reddened, and edematous ; 
constant and severe pain is present, and the teeth seem to 
be too long. It is difficult to masticate food. Speech is 
abnormal and sleep practically impossible. The symptoms 
of septic infection may present, as sweats, chills, and rigors, 
increased temperature and high-colored urine. Sometimes 
the antral walls may be so thinned and tense as to give 
crepitus on pressure. Dullness on percussion, and fluc- 
tuation may be found. Eventually the point of least re- 
sistance gives way, allowing the exit of accumulated pus 



Empyema of the Antrum. 305 

and the establishment of a more or less permanent fistula. 
This may be through any portion of the antral walls. 

Diagnosis. — When fully developed the diagnosis is easy. 
Prior to this, however, it is sometimes difficult. 

Prognosis. — Guarded, as complications may arise, and 
a chronic suppurative inflammation is quite likely to follow. 
Intracranial lesions may result regardless of any treatment. 

Transillumination. — While in typical forms of the an- 
trum this method is of undoubted aid, atypical types are 
unfortunately so common that little reliance can be placed 
upon this method, although it will assist in making a diag- 
nosis in a sufficient number of cases to be of value to the 
physician. The age and sex must be considered, as in chil- 




: 7/JW, 



Fig. 71. Antrum Illuminator. 



dren and women the antra are often higher than the floor 
of the nose, and the walls usually thicker. In the aged the 
walls are thinner. The best position for the lamp is in the 
nasopharynx. The examination should be made in a dark- 
ened room. In typical normal antra the cavities will be 
seen as clear areas on either side of the nose, but, as already 
stated, so many persons present atypical antral cavities 
that failure to get equal illumination does not positively 
indicate a morbid condition. 

Treatment. — This should consist of remedial, and in 
many cases surgical measures. If the antral opening is 
closed through swollen nasal tissues, especially when they 
present a soggy appearance, the introduction of a pledget 
of cotton saturated with glycerin will frequently deplete 
20 



306 Nose, Throat and Bar. 

the tissues sufficiently to allow drainage of the retained 
material. In some cases the ointment of salicylic acid 
answers better, as the results are more permanent. In- 
ternally, aconite and gelsemium or pulsatilla will often 
prove effective, provided there is no necrosis of the bone. 
If the discharge is purulent, calcium or silicea, or the two 
alternated, will give marked relief. When necrosis of the 
bony structures has occurred, gold and sodium chloride 
will be the best treatment. 

Operative measures, are frequently necessary to provide 
free drainage, the site for operative procedures depending 
upon the individual case. Drainage from below is undoubt- 
edly the best^ and should be obtained when possible, al- 
though the general rule is to treat through the nasal cav- 
ities when the disease is of nasal origin, and through the 
alveolar process when dental. No arbitrary rules can be 
laid down in these cases. If an artificial opening is to be 
made through the nasal cavity, the usual method is to use 
a spear-shaped knife. This is introduced into' the inferior 
meatus with the point toward the floor until just below 
the antral opening, then turning the point toward the an- 
trum and giving a sharp thrust, it will penetrate the wall. 
This opening will allow cleansing as well as free drainage. 
A curved trocar and canula, or a drill may also be used, 
but in cases of narrow nasal cavities these methods are 
often impracticable. In operating through the alveolar 
process, the canine fossa is the easiest of access. .If the 
teeth are all perfect, the opening may be made between the 
first and second molars, or between the second bicuspid and 
first molar. If either of the bicuspids or the first molar 
is absent, the opening should be through the socket (Jame- 
son). After opening into the antrum, if no granulations 
or other morbid growths are present, thorough irrigation 
should be made with a warm, saturated solution of boric 
acid, followed by i/iooo solution pyoctanin. In the major- 



Emphysema of the Antrum of Highmore. 307 

ity of cases packing the antrum with gauze, which should 
be replaced twice the first twenty-four hours, and after- 
wards usually once a day, is the best procedure. This 
should be continued as long as any morbid material is 
present. When the healing process is delayed through 
granulation tissue areas, the opening may be enlarged and 
the antrum curetted. 

Tuberculosis, Syphilis, Glanders, Actinomycosis. 

These affections are infrequent, and when present are 
usually the result of similar nasal diseases. 

Acute Infectious Diseases. 

Occasionally the antra are affected during nasal diph- 
theria, small-pox, erysipelas, etc. When this occurs it 
simply increases the symptoms already present. The gen- 
eral line of treatment is usually sufficient. 

Emphysema of the Antrum of Highmore. 

This is where there is an accumulation of gas in the 
antrum. As a rule, it is the result of the accumulation of 
gases from a decayed tooth communicating with the an- 
trum. The gases may be confined to the cavity by occlu- 
sion of the ostium maxillare. When a free escape of the 
gas occurs, a diagnosis of some nasal lesion is often made. 

Symptoms. — These depend upon the condition of the 
antral orifice. When partially or completely closed, there 
may be a sensation of intranasal pressure, dull in character, 
and a heavy, aggravating headache, increased on leaning 
forward. The functions of the eye, nose, or mouth may 
be disturbed. 

Diagnosis. — Frequently difficult, and must usually be 
made by exclusion. Caries of the teeth may aid in the 
diagnosis. Dental irritation of this region, with later an 



308 Nose, Throat and Bar. 

abatement of pain, and again pressure symptoms in the 
cheek, and a constant or intermittent ozenous odor should 
be viewed with suspicion. 

Prognosis. — Good, as the removal of the exciting cause 
usually results in a cure. 

Treatment. — The free exit of the gas, and referring the 
case to a good dentist. 

Foreign Bodies in the Antrum. — These may be ani- 
mate or inanimate. The former are seldom found, although 
insects and maggots have sometimes been found, having 
made their entrance from the nasal cavities through the 
antral opening. 

Inanimate Objects. — These may be the ends of dental 
or surgical instruments broken during operations upon the 
superior maxilla, or cotton, drainage tubes, etc. In a few 
cases foreign bodies find entrance through penetrating 
wounds of the cheek. Sometimes an intra-antral tooth, 
or a tumor, may cause the distress. 

Symptoms. — Identical with those of a catarrhal or sup- 
purative process. 

Diagnosis. — Conjectural as a rule, unless a history of 
trauma can be elicited. 

An exploratory opening is usually the only certain diag- 
nostic method. 

Treatment. — The ingenuity of the operator will often 
be. severely tested in these cases. Sometimes the foreign 
body can be grasped with delicate forceps, or a small probe 
bent to form a hook. A steel crochet needle may be useful 
Jn some cases, but care must be exercised not to entangle 
and injure the tissues. Occasionally free injections of tepid 
saline solution will bring the offending substance into a 
position where it can be easily removed. In the majority 
of cases it is necessary to open into the antrum, preferably 
through the canine fossa. Animate objects seldom make 
their way into the antrum, although such cases are re- 



Emphysema of the Antrum of Highmore. 309 

corded. The symptoms are then aggravated, especially if 
the object is alive, its motion producing an almost intoler- 
able pain. The treatment is similar to that for inanimate 
bodies. 

Mucocele of the Antrum. — This may result during 
or following a chronic inflammation of the antral mem- 
brane. The pathology is practically the same as found 
in the development of myxomatous masses in the nasal 
cavities. 

Symptoms. — About the same as in confined suppura- 
tion, only the course is slower, and there is not the sys- 
temic disturbance. In some cases the mass may occlude 
the antral opening, and cause an empyema. Usually there 
are no marked symptoms until the antrum becomes nearly 
filled, when there is a sensation of uneasiness and heavi- 
ness, and an aching pain which increases with the size of 
the growth. Facial deformity may become marked. The 
antral walls become thinned, and crepitus may be detected 
on palpation of certain areas. The symptoms are similar 
to those of empyema, but without the acute, rapid, and sys- 
temic manifestations. 

Diagnosis. — In the early stages, often impossible. In 
the later stages it is frequently difficult. Aspiration 
through the nasal walls will show whether the pressure is 
due to fluid or not. 

Prognosis. — Guarded, as it is usually difficult to cure. 

Treatment. — In some cases simply draining and wash- 
ing out the antrum will suffice. In many cases it is neces- 
sary to enter the antrum, either through the outer or nasal 
wall, and curette the antrum. The cavity is then packed 
with borated gauze, and this treatment continued until 
healing results. 

Tumors. — Tumors of the antrum are infrequent. 
Myxoma and osteoma are the most frequent, but fibroma, 
enchondroma, and angioma have been reported. Carci- 



310 Nose, Throat and Ear. 

noma and sarcoma may be either primary or secondary, but 
will always invade adjacent structures. Cysts and cystic 
degeneration within the antrum are rather frequent. They 
may be retention cysts, caused by dilatation of the mucous 
follicles. Cystic degeneration may result from inflamma- 
tory conditions of the mucous membrane. A dentigerous 
cyst may develop as the result of an inflammatory proc- 
ess extending from the root of a tooth which penetrates 
the antrum, and is covered by the mucous membrane. 

Diagnosis. — Usually must be made by an exploratory 
opening. 

Treatment. — Practically the same as in mucocele. 

Phlegmonous Inflammation. — Usually found asso- 
ciated with a similar condition of the upper respiratory 
tract. The symptoms are those of a very severe catarrhal- 
inflammation. This disease seldom occurs. Is rapidly 
fatal. 

Diseases of the Ethmoidal Cells. 

(i) Catarrhal inflammation, (a) Acute. (b) Chronic. 

(2) Suppurating Kthmoiditis. (a) Acute. (b) Chronic. 

(3) Mucocele and non-infected Fluid retention. (4) Spe- 
cific inflammations. (5) Tumors. 

The anatomical location and construction of the eth- 
moidal cells must be considered in both recognizing the 
diseases affecting them, and in making a diagnosis. In 
many cases a diseased condition is not recognized here, on 
account of other symptoms predominating. The nasal 
openings of the anterior cells are so situated as to be cov- 
ered by morbid discharges from either the frontal or maxil- 
lary sinuses. The posterior set are in a similar relation to 
the sphenoidal sinus, and there may be extension of inflam- 
matory action, or occlusion from various causes in the 
nasal cavities affecting these outlets, or there may be pri- 



Suppurating Ethmoiditis. 311 

mary involvement of the ceils, which later will affect the 
nasal tissues. 

Catarrhal Inflammation. 

Usually results from an acute rhinitis. The inflamma- 
tion may be either acute or chronic, the latter often becom- 
ing suppurative. 

Symptoms. — It is very difficult to differentiate, as the 
symptoms are frequently entirely masked by the nasal mani- 
festations. Pain may be more deep-seated and persistent 
than in a rhinitis. 

Diagnosis. — Very difficult, but at times the location and 
character of the pain will aid. 

Prognosis. — Favorable, unless suppuration follows. 

Treatment. — The same treatment given under acute 
rhinitis. 

Suppurating Ethmoiditis. 

Synonyms. — Purulent Ethmoiditis ; Ethmoidal Suppu- 
ration. 

Suppuration may be an acute process, but usually is 
chronic. It may result from simple catarrhal inflammation, 
especially when the tissues near the cell openings are af- 
fected. Generally one side only is affected, but may be 
bilateral. Very often other of the accessory sinuses are 
similarly diseased. Any obstruction of the drainage of the 
cells causing an accumulation of secretion may be a factor. 
Often seen in scrofulous or tuberculosis cases, and not in- 
frequently in the tertiary forms of syphilis. Erysipelas 
and acute infectious diseases may also be causes. Trau- 
matisms, or fracture of the base of the skull, or even intra- 
nasal operations, especially if much pressure is exerted on 
the septum, may lead to suppuration. Foreign bodies, 
either animate or inanimate, have also been reported as 
factors. 

Pathology. — The membrane is thickened and rough. 



312 Nose, Throat and Ear. 

The bony partitions become necrotic and are embedded in 
the purulent mass. Small sequestrae are sometimes found 
in the later stages. 

Symptoms. — Infrequently there are no symptoms, ex- 
cepting the discharge of pus. Some cases may run an 
acute or chronic course, showing slight characteristic symp- 
toms. The majority, however, are chronic and have char- 
acteristic, and usually, present severe symptoms, without 
any disposition to spontaneous recovery. Besides the usual 
symptoms of rhinitis, there is a deep-seated pain, referred 
to the back part of the orbit or the eyeball. As the disease 
progresses, the pain may extend to the temporal region. 
Pus escapes from the nostril of the affected side, and there 
may be a slight, or quite offensive odor. Sometimes the 
flow of pus may be increased or induced by pressure upon 
the eyeball. Inspection sometimes reveals the discharge 
from the anterior cells as it oozes out under the middle tur- 
binate, and occasionally that from the posterior and middle 
cells, high up in the posterior part of the superior meatus. 
When the patient is in the recumbent position, the dis- 
charge passes backward into the nasopharynx, and even- 
tually into the stomach, causing gastric disturbances. 
Usually, as the disease continues, small pieces of necrotic 
tissue and crumbling bits of carious bone will be found in 
the , discharge. The quantity of discharge varies from a 
small amount to a profuse and nearly continuous flow. Oc- 
casionally there may be a certain amount of material re- 
tained, only partial evacuation occurring. When this hap- 
pens there will be some symptoms of internal pressure, but 
not so decided as in complete retention. In retention there 
will be more or less severe disturbances of the eye, which 
becomes more or less prominent and congested, with in- 
creased lacrimation and edema of the lids. The mobility 
of the eyeballs is diminished, and may be immobile in se- 
vere cases. Diplopia or even blindness may occur. Ol- 



Suppurating Ethmoiditis. 313 

faction is impaired or destroyed. As a result of pus ab- 
sorption, chills, irregular fever and night sweats may occur, 
as well as a general depression of both the mental and 
physical systems. There may be symptoms of meningitis. 
If the pressure continues there will be increased distention, 
and frequently at the inner canthus of the affected side 
there will be a small, smooth tumor, which may rapidly 
increase in size,, increasing the symptoms of inflammation. 
When the distention is extreme, the consequent thinning 
of tissue will be followed by rupture and the escape of pus. 
This may occur in a few weeks, or only after the lapse of 
.years after the suppurative process has started. The direc- 
tion in which the rupture occurs varies ; it may be at the 
inner canthus, and an intractable, fistulous opening result. 
It may be the cause of an orbital abscess followed by pan- 
ophthalmitis. The maxillary sinus, frontal sinus, or the 
nasal chamber may be the point of selection. Often it 
opens into the anterior cranial fossa, producing a quickly 
fatal suppurative meningitis. After the escape of the pus, 
there is an amelioration of the most severe symptoms, but 
a persistent fistula remains. 

Diagnosis. — In a typical, uncomplicated case not very 
difficult. If suppurating disease of the other sinuses is 
present, it is difficult. The location of the pain, ocular dis- 
turbances, character of the nasal discharge, etc., will aid. 
Transillumination may aid in some instances, and in the 
later stages a probe passed over the affected area may give 
a grating or crumbling sensation. 

Prognosis. — Unfavorable. In some few instances the 
disease may spontaneously disappear. Usually it is very 
intractable, and is always a menace to life. 

Treatment. — In either the acute or chronic forms relief 
from the turgescence of the nasal tissues is important, but 
in the acute form the pus usually soon finds an exit. In 
either form, however, amelioration of the symptoms may 



314 Nose, Throat and Ear. 

be obtained by the use of pledgets of cotton saturated with 
glycerin or covered with salicylic acid ointment, and placed 
well up toward the roof of the nasal cavity. The ointment 
should not be used too frequently, as it will cause excessive 
irritation. Solutions which cause depletion of the nasal 
tissues may be employed, provided they can be carried up 
toward the roof of the nose. Any deformities of the nasal 
cavities should be corrected, so that free drainage can be 
obtained. Nasal polypi are often found in this condition, 
and should be removed. When the anterior portion of the 
middle turbinate is enlarged, impeding free exit from the 
anterior cells, the morbid portion should be excised. Gran- 
ulations and necrosed bone should be thoroughly curetted. 
Either Myles' or Bryan's curettes are preferable. Usually 
local anesthesia is all that is necessary for operating on the 
ethmoid cells, but in some cases general anesthesia is re- 
quired. After curettement, a careful cleansing of the area 
should be made with the salicylic acid wash, and a packing 
of borated gauze should be used for two or three days. A 
solution of asepsin is useful as an injection into the dis- 
eased areas. Powders are always to be avoided. The sys- 
temic treatment is the same as in antral disease. 

Mucocele and Non-infected Feuid-retention. — 
This is of infrequent occurrence, and presents the same 
etiological and pathological conditions as present in the 
other accessory sinuses. 

Symptoms. — Not well defined, and usually are not rec- 
ognized. The usual line of symptoms of chronic inflam- 
matory processes are present. In the later stages pressure 
symptoms are sometimes fairly well developed. Occasion- 
ally external deformity and. eye symptoms may occur. 

Diagnosis. — Quite difficult, and often made only after 
a long observation of the case. 

Prognosis. — Fairly good. 

Treatment. — Curettement and complete evacuation of 



Diseases of the Sphenoidal Sinuses. 315 

the morbid material and daily cleansing of the cavity until 
healing occurs. 

Specific Inflammations. — Comprising the specific in- 
flammations may be syphilis, tuberculosis, glanders, acti- 
nomycosis, and the acute infectious diseases. Implication 
of the ethmoid cells is always an unfavorable and some- 
times a fatal complication. 

Symptoms. — These may be localized, but are often un- 
recognizable on account of the general symtoms. 

Diagnosis. — Difficult. 

Prognosis. — Usually unfavorable. 

Treatment. — Must be directed to the primary cause. 

Tumors. 

Infrequently found. Myxomata are probably the most 
frequently found. Osteomata may also occur, and the 
tendency is to encroach upon or involve the orbit. Fibroma 
is very infrequent in this region. Carcinoma and sarcoma 
sometimes invade these sinuses, but usually are secondary. 

Treatment. — Surgical. In the malignant type the mor- 
bid growth has usually progressed to a stage that renders 
operations impracticable. 

Diseases of the Sphenoidal Sinuses. 

(1) Catarrhal inflammation, (a) Acute, (b) Chronic. 

(2) Empyema, (a) Acute, (b) Chronic, (c) Confined. 

(3) Tumors. (4) Syphilis, Tuberculosis, and Acute In- 
fections. (5) Mucocele. 

Pathological changes of the sphenoidal sinuses are usu- 
ally difficult to diagnose. The probabilities are that these 
cavities are seldom affected unless there is a preceding or 
accompanying affection of the nasal cavities or the other 
sinuses. The symptoms are obscure in the majority of 
cases. Excepting in rare instances it is practically impos- 



316 Nose, Throat and Ear. 

sible to get a view of the outlets of these sinuses. Usually 
unilateral. 

Catarrhal Inflammation. — This may result through 
extension of inflammatory conditions from the nasal cav- 
ities or nasopharynx, or even from inflammatory action of 
adjacent structures. The disease may be acute or chronic. 
There may be retention of the material which will result in 
degenerative changes or suppuration. 

Symptoms. — These are neither marked nor character- 
istic. A sensation of weight and fullness deep in the mid- 
dle region of the head may be complained of, and discom- 
fort in the occipital region, a dull headache, or pain along 
a portion or the entire distribution of the trifacial nerve. 
There may be dull pain in the posterior portion of the orbit 
of the affected side, and sometimes ocular disturbances. 
More or less mucus exudes, either intermittently or con- 
tinuously, and usually is discharged into the nasopharynx. 
At times the discharge may become inspissated, the masses 
occurring in the upper and posterior part of the nasal space. 

Diagnosis. — Difficult. Often entirely overlooked. 

Prognosis. — Good in uncomplicated cases of the acute 
catarrhal type. If complicated, and particularly in the 
chronic type, degenerative or suppurative changes may 
prove fatal. 

Treatment. — This should be along the line of treatment 
of other sinus lesions. 

Empyema op the: Sphenoidal Sinus. — The causes of 
this condition are similar to those producing catarrhal in- 
flammation. It may result from direct infection through 
the sphenoidal openings. Compound fractures, operative 
measures, or occasionally other traumatisms may be a 
cause. Syphilis, tuberculosis, and the acute infectious dis- 
eases may precede or be coincident. It may be found in 
necrosis of the bony structures, and may accompany or 
complicate tubercular meningitis. One or both sides may 



Diseases of the Sphenoidal Sinuses. 317 

be affected. It may be either acute or chronic, and a con- 
fined suppuration may result from either, and is always a 
menace to life. A small proportion of cases result from 
infection of a seromucous accumulation in the sphenoidal 
space. 

Symptoms. — Vary in severity. The character and loca- 
tion of pain is not constant. Headache may be dull and 
diffuse, or localized, sharp, and neuralgic. The pain may- 
involve either or both the supraorbital and infraorbital 
nerves, or if the material is confined, the neuralgic pain 
may follow the entire distribution of the fifth nerve on the 
affected side. This pain may or may not be constant. 
There is always more or less purulent discharge, which 
may be thin or comparatively thick, the odor of which is 
slightly or markedly fetid, and in the later stages it often 
contains small particles of bone. In some cases the dis- 
charge may be seen at the upper and posterior part of the 
nasal space, as the openings are located just above the pos- 
terior ends of the middle turbinates. Naturally the dis- 
charge is inclined to flow into the nasopharynx. It is often 
increased by pus from the ethmoidal cells. When the pa- 
tient is in the recumbent position it may accumulate in 
the vault of the pharynx causing nausea, or passing into the 
stomach produce gastric complications. Tinnitus aurium 
and vertigo may also be very annoying. In the acute type 
these symptoms may continue for a variable period, and 
then gradually diminish, but the chronic form is more likely 
to follow. The symptoms are always more severe when 
there is a confined suppuration. In the chronic type the 
symptoms are practically the same, only the pain is less 
severe, or the patient becomes more tolerant of the pain. 
Exacerbations are more or less frequent. The greatest 
change noticed in the discharge is that it is more fetid. 
Crumbling bone will also be found in the later stages. 
Hebetude is usually marked, the eyes heavy and dull, and 



318 Nose, Throat and Ear. 

a general physical depression. Sleep is disturbed, gastric 
disturbances are marked, the tongue heavily coated, and the 
breath sour. The patient shows the depression of suppu- 
rative drain. When the escape of the discharge is inter- 
fered with, the symptoms are all increased in severity. The 
causes of obstruction are similar to those found in the other 
sinuses. Systemic manifestations peculiar to pus formation 
are noted. Cerebral disturbances may result from exten- 
sion through contiguity of structures. As the internal pres- 
sure increases, disturbances of the eye become marked, 
there is photophobia, increased lacrimation, congestion of 
the lids and conjunctiva. If the distention continues, pres- 
sure against the optic nerve will cause diminution of the 
visual field. Scotoma and even total blindness may follow. 
The choked disk of optic neuritis will be seen with the oph- 
thalmoscope. Continuation of the swelling will result in 
restricted motion, or even immobility of the eyeball. Ex- 
ophthalmos may be a feature. There will be an aggrava- 
tion of ear symptoms, dizziness being almost continuous 
when in the upright position, also nausea and vomiting. 
The recumbent position will often have to be maintained in 
these cases. The swelling may be sufficient to close the 
nasal cavities. At this stage the pain may be so severe as 
to cause delirium. Thinning of the sinus walls will follow, 
unless relief is given, and rupture of the structure at the 
weakened point will relieve the most distressing symptoms. 
The rupture may take place into any of the adjacent cav- 
ities, as the orbit, skull above, or ethmoidal cells. 

Diagnosis. — In the early stages very difficult. Occa- 
sionally the sphenoidal symptoms are so prominent that a 
diagnosis can be made by exclusion. 

Prognosis. — Always guarded. The acute form may sub- 
side spontaneously, but as a rule it becomes chronic or con- 
fined. The danger of cerebral or orbital complications must 
be remembered. If an early recognition of the process is 
possible, surgical interference may relieve the condition, 



Diseases of the Sphenoidal Sinuses. 319 

Treatment. — The nasal cavities should be cleansed, pre- 
ferably with the salicylic acid wash. Irregularities of the 
nasal structures should be corrected. The cells may be 
opened by the use of a sharp gouge. In cases where the 
septum is comparatively straight and the posterior portion 
of the middle turbinate has been removed, the pus can often 
be seen oozing from the natural openings high up and near 
the septum. In using the gouge it should be passed through 
the nasal cavity along the upper border of the middle turbi- 
nate. The point of the instrument is directed backward and 
upward, thus entering the cells at the lowest point. Care 
must be taken in this manipulation for fear of passing 
through the cells into the cranial cavity. Posterior rhinos- 
copy is especially valuable in performing this operation. 
After the escape of the pus, the anterior wall and floor of the 
cavity should be carefully curetted, but the upper and ex- 
ternal walls should not be subjected to this procedure. 
Sometimes the sudden exit of the confined material will be 
followed by dangerous syncope. The cavity should be care- 
fully cleansed with a wash of calendulated boric acid, 
gr. viij to water fl. §j. 

Internally. — The same treatment as recommended under 
antral disease. 

Tumors. — Myxomata and osteomata sometimes occur. 
They are usually small, but may increase slowly and stead- 
ily, invading surrounding structures. Symptoms may or 
may not be present. When of considerable size, pressure 
symptoms may be present, especially affections of the eye- 
ball or optic nerve. When possible, the growth should be 
removed. Carcinoma and sarcoma are usually secondary. 
In these cases death soon results. 

Syphilis, Tuberculosis, and Acute Infections. — Any 
of these may affect the sphenoid cells, and always constitute 
a dangerous complication. 

Mucocele. — The conditions causing: mucocele in this 



320 Nose, Throat and Ear. 

location are identically the same as in the other accessory 
sinuses. Usually can not be diagnosed. 

Diseases of the Frontal Sinus. 

(i) Acute Catarrhal Inflammation. (2) Chronic Ca- 
tarrhal Inflammation. (3) Empyema, (a) Acute Purulent 
Inflammation, (b) Chronic Purulent Inflammation, (c) 
Confined Suppuration. (4) Mucocele. (5) Foreign Bodies. 
(6) Infectious Conditions. (7) Tumors. 

Acute Catarrhal Inflammation. 

This is not an infrequent complication of inflammatory 
diseases of the nasal tissues. As the development of the 
frontal sinuses is not complete under the age of twenty, it 
is seldom any morbid process is found in this location prior 
to this age. Catarrhal affections are more frequent than 
suppurative, as ordinarily drainage is more free than from 
the other cavities. The inflammatory process is usually 
secondary to nasal diseases. Any condition which will close 
the sinus outlet has a decided etiological bearing. The dis- 
ease may be a complication of, or follow, la grippe. Trau- 
matisms,, scrofulous or specific taints, improper use of the 
nasal douche, nasal tumors, foreign bodies, as well as some 
gastro-intestinal lesions, may have a causative influence. The 
acute inflammation may be the initital stage of a chronic 
type, or precede suppuration. The pathology is practically 
that of any acute catarrhal inflammation of mucous mem- 
brane. 

Symptoms. — These may be very slight, and not notice- 
able on account of the primary .condition, or they may be 
so severe as to mask the original disease. Usually pain is 
the most prominent feature, and may occur before, during, 
or following the nasal disease. One or both sinuses may be 
affected. The pain may be severe, dull, or sharp and neu- 



Acute Catarrhal Inflammation. 321 

ralgic, and is confined to the frontal region. Coughing, 
blowing the nose, inclining the head downward, or the use 
of cardiac stimulants increase the pain. A sensation of full- 
ness and weight in the forehead is marked ; this may increase 
in severity or be partially relieved by the escape of mucus 
into the nasal cavity. Tenderness along the course of the 
supra-orbital nerve is usually marked. Reflex eye symptoms 
are usually very pronounced. Nausea and vomiting fre- 
quently occur. 

Diagnosis. — Usually easy, the localized character of the 
symptoms determining the site of the lesion. 

Prognosis. — Good, as a rule, but may become chronic 
or suppurative. 

Trkatmknt. — Local. — The use of tampons, saturated 
with glycerin, placed well up in the nasal cavity of the af- 
fected side often give relief by lessening the turgescence of 
the tissues, and allowing the escape of the accumulated 
material. The ointment of salicylic acid also can be used, 
but as it will cause excessive tenderness if used frequently, 
it is not as good a remedy as the glycerin. 

Internally. — Gelsemium will form the basis of treatment. 
Bryonia, Pulsatilla, phytolacca, hydrastis, or hamamelis 
may also be indicated. The use of cocaine or suprarenal 
products in these cases is usually to be deprecated, as the re- 
laxation which follows their more or less persistent use ren- 
ders the patient more liable to succeeding attacks. A saline 
cathartic will usually afford some relief, and the bowels 
should be kept open; codeine or morphine may have to be 
given for the relief of pain. 

Chronic Catarrhal Inflammation. 

This may result from a continuation of an acute attack, 
or follow repeated acute attacks, and will result from the 
presence of the irritative cause, the most frequent cause be- 
21 



322 Nose, Throat and Ear. 

ing some obstruction to the exit of the frontal canal through 
a nasal lesion in the location of the opening. 

Pathology. — The membrane presents an irregular thick- 
ening and roughening. It may be granular, or in the later 
stages give evidences of myxomatous proliferation. 

Symptoms. — Nearly the same as in the acute attacks, 
but the pain is usually more severe and constant. There 
usually occurs at irregular periods a discharge of a clear 
mucoserous fluid, which is followed by relief of the aggra- 
vated symptoms. 

Diagnosis. — Usually easy, if the symptoms are observed. 

Prognosis. — Generally good. Suppuration may follow, 
and if distention results, it will modify the prognosis, as 
cerebral complications may follow, or there may be a fistu- 
lous opening. 

Treatment. — The treatment will not vary particularly 
from that of the acute form. 



Empyema of the Frontal Sinus. 
Acute Purulent Inflammation. 

This may appear at any time during an acute or chronic 
catarrhal attack, or even be an original inflammation of the 
frontal sinus. Suppuration is not very frequently found, 
probably on account of the facility of drainage from the 
sinuses. The causes are essentially the same as in the 
catarrhal conditions, but with an element favoring the for- 
mation of pus. 

Symptoms. — Practically as in catarrhal forms, only more 
severe. The pain is more of a throbbing character. The 
discharge is a bright yellow pus, which escapes from the 
nostril of the affected side. There may be an offensive odor. 
At times it is difficult to differentiate from disease of the 
other sinuses, but usually the local symptoms will predomi- 
nate. Transillumination is of doubtful value. 

Prognosis. — Guarded. Many cases terminate spontane- 



Empyema of the Frontal Sinus. 323 

ously, while others result in a persistent chronic suppura- 
tion. In some cases there may be occlusion of the exit 
causing a constantly increasing amount of pus in the cavity, 
which may result in cerebral complications. 

Chronic Suppurative Inflammation (Chronic Puru- 
lent Inflammation'). 

This may follow an acute attack, or be the result of re- 
peated attacks. The continuance will depend upon the ex- 
citing cause, as well as upon the condition of the outlets of 
the sinus. Any cause interfering with free drainage will 
prolong the disease. 

Pathology. — A thickened, rough, pyogenic membrane 
bathed with yellow and sometimes fetid pus. 

Symptoms. — Simply modifications of those already given. 




MAX WOCHER &. SON, OIN., O. 

Fig. 72. Frontal Sinus Illuminator. 

Diagnosis. — Usually easy, but sometimes the case must 
be under observation for some time. 

Prognosis. — Guarded. 

Confined Suppuration. — This is the most dangerous 
of the suppurative types. It may occur at any time during 
an acute or chronic attack. The causes of occlusion may 
be any morbid condition of either the sinus or nasal cavity. 

Symptoms. — Similar to those found in abscess formation 
of any closed cavity. The pain is constant, throbbing, and 
boring in character, and confined to the frontal region. 
There is a persistent and severe headache, sleep is practically 
impossible. The tissues over the sinuses are swollen, edema- 
tous, and reddened. The eyes are suffused. Pressure either 
over the sinuses or at the inner angle of the eye is extremely 
painful. Systemic symptoms of pus formation are present. 



324 Nose, Throat and Bar. 

If not relieved, the pressure will produce bulging over the 
affected cavity, and especially at the inner angle of the orbit. 
Diplopia, the result of displacement of the eyeball, follows, 
or the optic nerve may be subjected to pressure, causing 
more or less blindness. Olfaction may be destroyed, and 
cerebral complications are likely to occur. After a time the 
walls become so thinned that a sense of fluctuation or crack- 
ling may occur on palpation. When allowed to run its 
course, rupture will follow in the line of least resistance, 
and the abscess will empty. This may be in any direction, 
the inner orbital angle, into the orbit, into the space between 
the dura mater and inner table of the skull, into the nasal 
cavity, or it may open in through the external tables of the 
frontal bone. When rupture occurs, giving free exit to the 
purulent material, the relief is immediate. 

Diagnosis. — Usually easy after the local swelling and 
systemic symptoms have occurred. Transillumination may 
be of confirmatory value. 

Prognosis. — Always guarded. As a result of the disease, 
meningitis may follow. Sometimes panophthalmitis occurs, 
necessitating the removal of the affected eye. An obstinate 
fistulous tract may also be formed. 

Treatment. — Local. — Same as given under catarrhal 
inflammation. 

Internally. — The use of calcium sulphide or silicea, but 
dependence must be placed upon surgical measures as a 
rule. Bryan's operation is preferable in the majority of 
cases, as the resulting scar is not seen. This operation 
should not be attempted until all nasal obstructions to the 
sinus openings have been removed, as in some cases this 
will allow drainage. The ethmoidal cells should also be ex- 
amined, and if carious, curetted. When the external oper- 
ation is necessary, the eyebrow is shaved, and the integument 
of the forehead prepared as in any surgical operation. The 
skin is then drawn upward, and the incision commenced 



Mucocele of the Frontal Sinus. 325 

just at the median side of the supra-orbital notch, carried 
down to the bone and continued to the inner angle of the 
orbit, following along the lower border of the supra-orbital 
ridge. This flap of skin and periosteum is raised. If there 
is not space enough to apply the trephine, the incision should 
be carried across the root of the nose to the corresponding 
inner angle. A small crown trephine about 1 cm. in diam- 
eter is placed about two lines outside the median line and 
the same distance above the supra-orbital ridge. When the 
button of bone has been removed, all carious and granula- 
tion tissue should be removed, the frontonasal duct enlarged 
and a self -retaining drainage tube introduced. The parts 
should be thoroughly irrigated with an antiseptic solution, 
and the lining membrane touched with a solution of sali- 
cylic acid, gr. x, Lloyd's thuja, Lloyd's hydrastis, aa 3ij, 
aqua gss. The wound is then closed. If the fronto- 
ethmoidal cells and ethmoidal cells proper are carious, the 
diseased tissue should be curetted, working within the sinus 
and using the little finger of the other hand in the nose as a 
guide. In these cases a large opening is made from the sinus 
into the nasal cavity, and instead of a drainage tube, borated 
or iodoform gauze is packed in the cavity and brought down 
through the nose. The wound is closed as in the preceding 
operation. After the gauze is removed the cavity may have 
to be irrigated, when a curved canula can be used. Any 
mild, unirritating antiseptic solution may be used. 

Mucocele of the Frontal Sinus. 

This results from a long continued catarrhal inflamma- 
tion, where there is either the formation of myxomatous 
masses, mucoid degeneration or proliferation of mucous 
cysts. The growth of these elements develops a mass, held 
by a thin membrane, consisting mostly or entirely of the ele- 
ments constituting normal mucus. 

Symptoms. — Practically the same as in free mucoserous 



326 Nose, Throat and Ear. 

fluid. There may be symptoms of internal pressure, but 
the external phenomena are absent, as well as the systemic 
symptoms of pus. The pain is less severe. The sinus walls 
may become thinned, and sometimes there is escape of the 
sinus contents. Degenerative changes, even pus, may result. 

Diagnosis. — Difficult. The pressure symptoms with ab- 
sence of pus poisoning and history may lead to a diagnosis. 
It is practically impossible to differentiate from any tumor 
in this location. 

Prognosis. — Fairly favorable. Empyema may occur. 
There may also be cerebral or ocular complications. 

Treatment. — Sometimes spontaneous rupture and dis- 
charge occurs. Usually surgical measures are required. In 
most cases this can most easily be done with Palmer's frontal 
sinus drill, perforating through the frontonasal duct from 
the nose. Curettement of the sinus should then be done. 
When successfully performed free drainage at least will 
result, even if a cure is not accomplished. When a cure does 
not follow the operation, the external operation must be per- 
formed. 

Foreign Bodies. 

These may be animate or inanimate. Animate foreign 
bodies may be worms or larvae. This condition is infre- 
quently seen. The symptoms are those of most intense pain, 
suppuration, and fetid discharge. Ulceration and necrosis 
soon follow. The diagnosis is made by the presence of the 
bodies in the nasal discharge as well as the localized symp- 
toms. Cases of this character are more often found in trop- 
ical climates than in the temperate zones. The prognosis is 
guarded. 

Inanimate objects may be bullets, shot, pieces of metal, 
etc., the history of a traumatism usually being sufficient for 
determination. Symptoms may be entirely absent, or they 
may be those of a chronic catarrhal or suppurative action. 
These cases are infrequent. 



Foreign Bodies. 327 

Treatment. — Either surgical, or if animate bodies the use 
of an etherial solution, chloroform vapor or emulsion, fol- 
lowed by flushing with an antiseptic solution. 

Infectious Conditions of the Frontal Sinus. — These 
may be erysipelas, diphtheria, tuberculosis, la grippe, syph- 
ilis, etc., but are usually secondary to nasal involvement. 

Tumors. — These may be primary, or associated with 
similar growths of adjacent structures. Those most fre- 
quently found are fibroma, myxoma, and osteoma. Cystic 
tumors may occur at any age, or may be congenital. In 
character they are either that of mucocele or steatomatous. 
Malignant tumors are usually secondary, and are fatal. 
Tumors of the frontal sinus are always dangerous. When 
benign and recognized early, an external operation may 
prove curative. 



CHAPTER XV. 
DISEASES OF THE NASOPHARYNX. 

(a) Acute and Chronic Inflammatory Diseases. — (i) 
Acute Nasopharyngitis. (2) Simple Chronic Nasopharyn- 
gitis. (3) Atrophic Nasopharyngitis. (4) Hyperplastic 
Nasopharyngitis. (5) Specific Inflammations, (a) Syph- 
ilis, (b) Tuberculosis, (c) Lupus, (d) Glanders, (e) 
Actinomycosis. (6) Neuroses. 

Acute Rhinopharyngitis. 

Synonyms. — Acute catarrh of the nasopharynx; acute 
postnasal catarrh ; acute nasopharyngitis ; acute retronasal 
catarrh. 

This is an acute catarrhal "inflammation of the naso- 
pharyngeal mucous membrane. 

Etiology. — Predisposing causes: The most active cause 
is climatic changes, especially in the spring and fall. The 
patient's powers of resistance to these changes are also fac- 
tors. A hypersensitive condition of these tissues is not in- 
frequently found in neurasthenic patients. The disease is 
infrequently seen in children; but a scrofulous diathesis is 
a predisposing condition. 

Exciting Causes. — It may accompany either an acute 
pharyngitis or rhinitis, or may be an exacerbation of a 
chronic catarrhal inflammation of this region. It may also 
result from extension of an inflammatory process in either 
the nose or pharynx through continuity of tissue. Local 
irritation caused by the inhalation of dust or chemical fumes 
may be a cause. Any of the conditions which might pro- 

328 



Acute Rhinopharyngitis. 329 

voke an acute rhinitis, may involve the nasopharynx. 
Among the infectious diseases, scarlet fever, diphtheria, and 
measles are quite likely to be followed or complicated by 
acute rhinopharyngitis. 

Pathology. — Practically the same as in acute catarrhal 
inflammation of any mucous membrane. 

Symptoms. — These vary according to the severity of the 
case. When the disease accompanies an acute rhinitis or 
pharyngitis, it may not be recognized. When occurring in- 
dependently, however, the symptoms are quite well defined. 
The attack is sudden, usually with a slight rise in temper- 
ature, not often reaching 101 F., malaise, disturbance of 
the stomach and bowels, and tongue coated. A dryness of 
the postnasal space is present, which is very uncomfortable, 
as well as a sensation of tightness, which is increased on 
swallowing. 

A neuralgic pain is usually complained of, and is referred 
to the pharyngeal vault, roof of the mouth, angles of the 
jaws, or the vertex, and is generally presistent during the 
attack. Slight hemorrhages may occur. The dryness con- 
tinues for one or two days, or until secretion commences. 
The secretion at first is quite clear, but thick and tenacious ; 
then it changes to a white color, and finally becomes puru- 
lent. The secretion is adherent to the mucous membrane, 
and on account of the irritation produced, a more or less 
constant "hawking" and spitting result. Sometimes the se- 
cretion is expelled through the nose, but as a rule through 
the mouth. Some of the secretion is unavoidably swallowed, 
and this increases the gastric disturbance. 

The secretion may produce an acute rhinitis through irri- 
tation. If an aggravated case, catarrhal ulcers may form, 
the hearing may be impaired, and the voice become hoarse 
through impeded circulation. Cough is not often present. 
After ten days or two weeks the symptoms gradually dis- 
appear, and the tissues regain approximately their normal 



330 Nose, Throat and Ear. 

condition. Very infrequently there is bronchial or tracheal 
involvement. 

Inspection of the nasopharynx during the early stage re- 
veals a reddened, swollen condition, with dry, glazed surface, 
and tortuous, congested vessels. In the later stages the 
secretion will be seen clinging to or hanging from the walls, 
filling the crypts of Luschka's tonsil, as well as Rosenmul- 
ler's fossae. 

Diagnosis. — The history of the case, but especially by 
posterior rhinoscopic examination. 

Prognosis. — Favorable. 

Treatment. — Local treatment is of no especial value, ex- 
cepting to cleanse the surfaces, and for this purpose any of 
the alkaline washes will do. Internally, during the initial 
stages, jaborandi. If there is much burning, as sometimes 
occurs, rhus tox. should be added. For the pain, aggra- 
vated on swallowing, bryonia. When the -mucous follicles 
are engorged, phytolacca. The remedy generally indicated 
after secretion is established is potassium bichromate, 
i/ioo gr., giving it every three hours. When the secretion 
becomes purulent, lime, either as lime water or the sulphide 
of lime. After the subsidence of the disease, hydrastis and 
Phytolacca should be administered for several weeks, or until 
the tissues regain their normal activity. 

Simple Chronic Rhinopharyngitis. 

Synonyms. — American catarrh ; chronic catarrh of the 
nasopharynx ; chronic postnasal catarrh ; chronic retronasal 
catarrh ; simple chronic nasopharyngitis ; chronic rhino- 
pharyngitis ; catarrh of the pharyngeal bursa ; chronic ade- 
noiditis. 

This is a simple chronic catarrhal inflammation of the 
nasopharynx, characterized by a constant secretion of tough, 
tenacious mucus, which may be purulent, or in cases of 
long standing may form firm crusts. The nasopharyngeal 



Simple Chronic Rhinopharyngitis. 331 

wall is more or less covered with this tenacious secretion, 
which gradually passes down to the pharynx, and causes 
the patient to make more or less constant efforts to clear the 
throat by "hawking." Acute attacks are frequent without 
any apparent cause. Rhinitis or pharyngitis may also be 
present. 

Etiology. — Usually the result of repeated acute attacks, 
the cause being practically the same as in acute attacks of 
rhinitis or pharyngitis. It may also follow a stubborn at- 
tack of acute rhinopharyngitis, where the exciting cause is 
continuous. It often accompanies either a chronic pharyn- 
gitis or rhinitis, and may be" an extension of either or both 
to this region. 

Predisposing Causes. — It is more frequently found in 
youth than in adult life. Heredity may have an influence, 
through peculiarities of the nasal structure, or a low resist- 
ing power. Among the latter can be classed the neurotic, 
rheumatic, gouty, scrofulous, anemic, etc., diatheses. Ali- 
mentary wrongs undoubtedly are predisposing factors. The 
exanthemata are also exciting causes. The improper use 
of the voice in public speaking and singing ; abnormal con- 
ditions of the nasal, faucial, or pharyngeal region may also 
cause such a condition. 

Exciting Causes. — Besides the predisposing causes, the 
same conditions as produce a rhinitis or pharyngitis will be 
equally as active in nasopharyngeal disease. The position of 
the nasopharynx must also be considered, as irritating ma- 
terial frequently lodges here, and it is very difficult for the 
patient to cleanse this space. ' 

Pathology. — The same general characteristics of simple 
inflammation of mucous membranes is observed. It usually 
is paler than normal, somewhat edematous, and the mucous 
glands are reddened and prominent. 

Symptoms. — Usually an illy defined sensation of uneasi- 
ness. A dryness and sensation of a foreign body in the naso- 



332 Nose, Throat and Ear. 

pharynx. In some cases the effort to dislodge this will cause 
vomiting. This discomfort is usually most marked in the 
morning. In severe cases the patient is almost continually 
trying to clear the throat, on account of the more or less 
constant "dropping." This material in conjunction with the 
repeated efforts to clear the throat, will cause irritation of 
the lower pharynx, which often produces an annoying spas- 
modic cough. The character of the discharge varies accord- 
ing to the stage of the disease. In the early stages it is 
thick, usually clear, and tenacious or gelatinous. As the 
disease progresses it becomes mucopurulent or purulent, 
varying in color from a light yellow to a dirty greenish 
color. After a time there is a tendency to the formation of 
crusts or scabs, or possibly thick, semi-solid masses. If 
saprophytic infection occurs, there will be a disagreeable 
odor, which is frequently augmented by the fetid breath 
found with gastric disorders. The expectoration is often 
streaked with blood. As a rule the Eustachian tubes and 
tympani are implicated, an annoying tinnitus aurium and 
impaired hearing being complained of. The voice is weak 
and muffled, clearing in a measure after expectoration. De- 
pending upon the individual as well as the severity of the 
case, there may be dull frontal or occipital headache, pain 
in the upper cervical region, dull, heavy, tired feeling in the 
head, disinclination or incapacity for work of any kind, and 
occasionally there may be temporary loss of memory. Dis- 
turbances of the digestive tract are usually present, most 
frequently of the atonic type. A chronic rhinitis, pharyn- 
gitis, or laryngitis often augment the discomfort of the pa- 
tient. Exacerbations are frequent. Inspection of the vault 
of the pharynx, prior to cleansing, will reveal swollen tis- 
sues, the tubal openings filled with secretion, the walls of 
the postnasal space covered more or less completely with 
the characteristic secretion. This is especially marked over 
the pharyngeal tonsil. In cases of long standing the soft 
palate and uvula may be swollen and relaxed. 



Atrophic Nasopharyngitis. 333 

Diagnosis. — Usually easy. The history, efforts to clear 
the throat, and a rhinoscopic examination will readily deter- 
mine the condition. 

Prognosis. — Guarded. While not a fatal disease, the 
complications which may arise, as well as the liability of 
atrophic changes occurring, must be remembered. Also the 
chronic course, and the disinclination of most persons to 
continue treatment for a sufficient time to effect a cure will 
have to be considered. In some cases the disease disappears 
when middle age occurs. 

Complications. — A chronic inflammatory condition ap- 
pears to render the patient more susceptible to infectious 
diseases, particularly in early life. The unconscious swal- 
lowing of the accumulated discharge often causes severe 
gastric disturbances. The irritation caused by the tenacious 
material in the nasopharynx may also cause irritation of the 
pharynx and larynx, rendering these structures more liable 
to inflammatory lesions, which may also extend to the bron- 
chial and pulmonary tissues. Aural lesions are not infre- 
quent. 

Treatment.— Local. — The necessity of cleansing the 
postnasal space is acknowledged, but the long continued and 
repeated use of any solution will probably aggravate the 
condition. The use of a saline solution, or preferably the 
salicylic acid wash, often enough to keep the surfaces free 
from the secretion, will be all that is required. The main 
reliance must be upon internal medication. Potassium bi- 
chromate, jaborandi, phytolacca, hydrastis, potassium iodide, 
lime, apis, apocynum, nux, ignatia, are usually required in 
this condition. 

Atrophic Nasopharyngitis. 

In the nasopharynx an atrophic condition is generallv 
found with an atrophic rhinitis, but it may be independent 
of such a nasal lesion. The change of character of the 



334 . Nose, Throat and Ear. 

mucous membrane epithelium acts as a bar to the extension 
of inflammatory processes, even though there is continuity 
of tissue. 

Atrophic changes in the vault of the pharynx are iden- 
tical with the same condition in the anterior nares. The 
contour of the nasopharyngeal space may influence the con- 
dition. 

In many persons the nasopharyngeal space is very nar- 
row, the posterior wall curving forward at the point where 
the soft palate normally comes in contact with the naso- 
pharyngeal wall. When this occurs the attachment of the 
faucial arch to the lateral walls of the pharynx causes the 
formation of a pocket on each side. As there is a tendency 
in atrophic conditions for the accumulation of secretion, 
these pocket formations are liable to increase the collection 
of secretion. The irritation produced by this retained ma- 
terial, I have found, will usually cause an increase of the 
size of the pockets through increasing the amount of ad- 
hesions'. 

When the pockets are present, the patient has the sensa- 
tion of a foreign body in the pharynx, and there is more or 
less constant hawking in the effort to clear the throat. The 
secretion is particularly tenacious and may adhere to any 
portion of the pharyngeal walls. 

The most important complication of this form of naso- 
pharyngitis is the involvement of the Eustachian tubes. 
The disease may invade the mucous tissues of the tubes, -or 
the ventilation of the tympanum may be obstructed through 
the accumulation of secretion in or about the tubal openings. 

The pathology is the same as in atrophic rhinitis. 

Diagnosis. — The associated conditions will make diag- 
nosis comparatively easy as a rule. 

Prognosis. — This will depend upon the changes which 
have taken place. 



Hyperplastic Rhinopharyngitis. 335 

Treatment. — Local treatment in these cases is of sec- 
ondary importance, although in many cases an alkaline wash 
will materially aid in cleansing the tissues. Internally, po- 
tassium bichromate, phytolacca, jaborandi, or hydrastis will 
be necessary. 

Various methods of getting rid of the lateral pockets 
have been tried, the majority being to cauterize by some 
means, so the pockets would become closed through inflam- 
matory processes. These measures are to be condemned, 
as the space between the oropharynx and vault of the phar- 
ynx is still more reduced. In all these cases of narrowed 
space, even without decided pockets, I have loosened, 
stretched, or divided the posterior faucial pillars from the 
lateroposterior wall. In nearly every case there has been 
a marked improvement in a very short time, the irritation 
and cough rapidly disappearing. 

Hyperplastic Rhinopharyngitis. (Hyperplastic Naso- 
pharyngitis.) 

The causes of this condition are the same as produce the 
same state in the nasal cavities. There is an excessive 
growth of the submucosa connective tissue, which is not 
followed by contraction. The nasopharyngeal tissues usu- 
ally involved are the posterior and inferior ends of the turbi- 
nates, especially the middle and inferior. It may be associ- 
ated with the same disease of the anterior nasal cavities. 
The appearance of the structures on rhinoscopic examina- 
tion does not vary much from a simple chronic rhinitis. The 
tissues, however, are smoother, although they may be lobu- 
lated. 

Symptoms. — The postnasal obstruction is the most prom- 
inent. 

Treatment. — This is surgical in the majority of cases. 



336 Nose, Throat and Ear. 

Neuroses of the Rhinopharynx. 

Reflex disturbances are not uncommon, the most frequent 
being laryngismus stridulus, stammering, and general con- 
vulsive attacks. Alimentary disturbances, as vomiting, eruc- 
tation, etc., may be reflex, but usually are the result of in- 
gestion of secretion from the nasopharynx. Aural compli- 
cations are usually due to extension of the inflammatory 
process through the Eustachian tubes, and not reflex. 



CHAPTER XVI. 

DISEASES OF THE UVULA AND 
SOFT PALATE. 

(i) Malformations. (a) Bifid. Rudimentary. (b) 
Elongation. (2) Inflammatory Diseases, (a) Acute uvu- 
litis. '(b) Chronic uvulitis. (c) Ulceration. (3) Non- 
inflammatory Diseases. (a) Adhesions. (b) Neuroses. 
(1) Hyperesthesia. (2) Anesthesia. (3) Paresthesia. 
(4) Neuralgia. (5) Spasmodic Contraction. (6) Paraly- 
sis. (7) Acute Bulbar Paralysis. (8) Chronic Bulbar 
Paralysis. (9) Apoplectiform. Bulbar Paralysis. (10) 
Herpes of the Fauces. 

Bifid and Rudimentary Malformations. 

A bifid uvula is the most common anomaly of the uvula, 
although congenital absence or imperfect developments have 
been noted. Bifurcation may, be simply at the tip of the 
uvula, or may divide the entire structure. Unless it proves 
a source of irritation, it is not necessary to do anything with 
it. When a morbid condition results, however, as a result 
of the malformation, the median sides of the uvula should 
be denuded of the mucous membrane. One or two stitches 
may be necessary, passing through the body of the uvula. 
Healing is rapid, and the cicatrization resulting will shorten 
the uvula. The operation can be done under cocaine anes- 
thesia, or the cocaine autospray. 

Elongation of the Uvula. 

No fixed rule for the normal length of the uvula can be 
given. In the adult, however, it is seldom longer than 
22 • 337 



338 



Nose, Throat and Ear. 



3/8 inch, if longer some indications of irritation may be 
present. When the organ drags upon the base of the tongue, 
it may be considered abnormally long. 

Etiology. — Congenital fullness of tissue, general relax- 
ation of the faucial tissues, due to the general physical con- 
dition, partial paralysis following infectious diseases. 
Chronic catarrhal inflammations of the nasopharynx, 
growths or structural changes in the pharyngeal vault, are 
the most frequent causes. 

Pathology. — The diameter of the uvula is not often in- 
creased, excepting in chronic catarrhal inflammation. The 




^^^ 




73 74 

Fig. 73. Elongation of the uvula. Fig. 74. The same, on at- 
tempting a high note, showing the wrinkling of the relaxed tissues. 

length is increased either by an increase of white fibrous and 
yellow elastic tissue, similar to that of the normal uvula, or 
by a relaxation of the submucus structures, allowing what 
appears to be a slipping of the mucous membrane over the 
azygos muscle. The cause of the elongation contributes to 
the appearance of the uvula. 

Symptoms. — There is a tickling or irritating sensation, 
causing frequent attempts to clear the throat, either by ex- 
pectoration or swallowing; more or less constant irritative 
cough, increased on lying down, as the uvula then rests 
against the pharyngeal wall. Damp, "muggy" weather also 
increases this cough, as there is then more relaxation of the 



Inflammatory Diseases. 



339 



tissues than in dry weather with a high barometeric pres- 
sure. In aggravated cases, asthmatic or choking attacks, 
spasm of the glottis, chronic laryngitis, and faulty phonation 
may result. 

Diagnosis. — Inspection will usually reveal the condition. 

Prognosis. — Good. 

Treatment. — When the relaxation is temporary or simply 
the result of an acute inflammatory condition, the removal 
of the cause is all that is required. In the chronic types, 




Fig. 75. An apparent slipping of the mucous membrane 
over the muscular tissue. 



however, the use of local measures is simply temporizing, 
the removal of a small portion of the tip being necessary. 
Sajou's uvula scissors are the easiest managed, care being 
taken not to remove too much tissue. Kyle has employed 
the method of removing a A shaped portion by grasping 
the tip of the uvula with forceps, simply steadying the struc- 




FiG. 76. Sajou's Uvula Scissors. 

ture, then transfixing with a small sharp-pointed bistoury, 
making the wedge-shaped incision. The raw surfaces may 
be held in apposition by the use of sutures. 



340 Nose, Throat and Ear. 

Inflammatory Diseases. 

Acute: Uvuutis. 

Synonyms. — Edema of the uvula ; Acute infiltration. 

Etiology. — An elongated uvula is more liable to an acute 
inflammation or an injury than a normal one. Acute uvu- 
litis is frequently seen in rachitic persons and in digestive 
wrongs. Extension Of inflammation from adjacent struc- 
tures is frequent. A swollen edematous uvula is often found 
during an attack of acute pharyngitis or quinsy. The swal- 
lowing of irritants produces an acute inflammation with 
edema. Frequently the primary cause is obscure. 

Pathology. — The inflammatory stages are more rapid 
than ordinary, as there is lack of both muscular and bony 
support. 

Symptoms. — Usually the first symptom is that of a for- 
eign body, which gives a sensation of irritation and tickling 
of the fauces and pharynx. There is an effort to swallow or 
expectorate the supposedly foreign body. Cough is usually 
also an accompaniment. Sometimes there is difficulty and 
pain on swallowing, and dyspneic symptoms may be present. 

Diagnosis. — Easily made on inspection. 

Treatment. — In aggravated cases it may be necessary to 
puncture the uvula with a small bistoury, but this is seldom 
necessary. Internally apis or apocynum, alternated or com- 
bined, will reduce the edema quite rapidly. The treatment 
of the exciting cause, when of an acute inflammatory nature, 
will effect a cure. 

Chronic Uvuutis. 

The acute process may become chronic. This form is 
usually found with a chronic rhinopharyngitis or chronic 
pharyngitis. 

Symptoms. — Usually so slight as to be disregarded. The 
treatment of the associated disease usually affords relief. 

Abscesses, either acute or chronic, may occur in the 
uvula or soft palate, but are infrequent. 



Non-Inflammatory Diseases. 341 

Ulceration. 

Infrequently there may be ulceration of the uvula with- 
out implication of adjacent structures. Tubercular or syph- 
ilitic ulceration may attack the uvula either primarily or sec- 
ondarily, the characteristic appearances of the lesion being 
the same as seen in other locations. 

Treatment. — In the simple form of ulcers, touching with 
solid stick of silver nitrate is all that is necessary. If syph- 
ilitic, the surfaces should be carefully cleansed, and the areas 
touched with Lloyd's thuja. Internally, the use of the reme- 
dies given under nasal rhinitis should be followed. 

Mycosis. — This disease when involving the uvula is 
usually an extension from the pharynx, the characteristic 
small whitish masses projecting from the surface. The 
treatment is given under mycosis of the pharynx. 

Emphysema. — The uvula and soft palate may be the 
site of emphysema, as the result of careless manipulation of 
the Eustachian catheter. 

Treatment. — Numerous punctures. 

Non-Inflammatory Diseases. 

Adhesions. 

These usually result from syphilitic lesions on the pos- 
terior portion of the uvula or velum, with corresponding 
ulceration on the posterior pharyngeal wall. This deformity 
depends upon the union of the adjacent surfaces. When due 
to syphilis the characteristic stellate cicatrices are seen. Ex- 
tensive burns or lupus may present similar pictures, but are 
easily eliminated as » rule. The adherence may be partial 
or complete. It may result either from acquired or hered- 
itary syphilis, which can usually be readily determined by 
the appearance of the nasal tissues and teeth. Perforation 
of the velum, half arches, and even the hard palate may 
occur. Any of these abnormalities usually change the char- 
acter of the voice. 



342 Nosk, Throat and Ear? 

Treatment. — If in the active stage, prompt measures may 
afford partial relief. In perforation of the hard palate, ordi- 
nary chewing gum may be used to close the perforation. 
This is readily replaced. When.extensive adhesions between 
the velum and posterior pharyngeal wall are present, oper- 
ative measures may benefit, provided proper internal medi- 
cation is employed, otherwise it is useless. The patient 
should usually be put on preparatory treatment. Several 
cases operated upon successfully were treated with anti- 
syphilitic remedies before and after the operation. 





Fig. 77. Syphilitic perforations of velum. Characteristic stel- 
late cicatrix of left side of pharyngeal wall and adhesion of the 
faucial tissue to the posterior pharyngeal wall. 

Neuroses. 

Anesthesia, Hyperesthesia, and Paresthesia of the 
velum and its appendages may occur. These probably de- 
pend upon some anomalous condition of adjacent structure, 
or some systemic wrongs. The treatment will necessarily 
be directed to such conditions. 

Neuralgia. — In hysterical persons this may be found as 
a local manifestation. It may be associated with follicular 
or lateral pharyngitis or some abnormal state of the tonsillar 



Non-Inflammatory Diseases. 343 

structures. Remedies that will improve general nutrition 
are indicated. 

Spasmodic Contraction. — This is usually of the levator 
palati, but is not often seen. No definite cause is known. 

Paralysis. — The muscles of the velum or uvula may be- 
come paralyzed as a result of inflammatory action of the 
fauces, especially .in diphtheria. It may be central, local, 
or the result of general blood depravation. 

Symptoms. — Deglutition is impaired and there is a tend- 
ency for fluids to enter the nasal cavities. The voice is 
thick and there is a nasal twang. Articulate speech is im- 
paired or at times impossible. As there is difficulty in ex- 
pectorating, the mouth becomes filled with saliva, which 
may escape from the corners of the mouth. One or both 
sides may be affected. When but one side, the tissues will 
be dragged toward the healthy side. 

Diagnosis. — Generally easy. 

Prognosis. — Depends upon the cause. If due to diph- 
theria, a cure usually results, although it may take several 
months. Nux, strychnine, or ignatia usually forms the basis 
of treatment. Electricity is also advocated in these cases. 

Acute Bulbar Paralysis. — Very seldom occurs. The 
onset is sudden, the progress of paralytic development rapid, 
and death soon follows. There is at first headache, giddi- 
ness, possibly vomiting, soon followed by difficulty in walk- 
ing. While the patient retains consciousness, there is diffi- 
culty in swallowing and articulating, which rapidly increases 
in severity. Death from cardiac involvement usually occurs 
in from four to ten days. Treatment has been ineffectual. 

Chronic Bulbar Paralysis. — Duchenne describes as 
labioglossopharyngeal paralysis a condition usually resulting 
from degenerative changes in the bulbar nuclei of the me- 
dulla, which is an insidious disease. There is gradual in- 
volvement of the larynx, pharynx, tongue, etc. Death may 



344 Nose, Throat and Ear. 

rapidly result, or the patient may linger for several years, 
finally dying from starvation. 

Apoplectiform Bulbar Paralysis. — A hemorrhage, 
embolism, endarteritis, or softening implicating the ganglia 
in the floor of the fourth ventricle, may cause a sudden apop- 
lectiform paralysis of the. velum, contiguous structures, and 
pharynx, which usually is temporary, but may terminate 
fatally. A positive localization of the origin is usually diffi- 
cult. 

Symptoms. — Usually come on suddenly during sleep. 
There will be on awakening, malaise, a disposition to keep 
quiet, dizziness, and sometimes headache with vomiting. 
Occasionally the extremities are somewhat affected. Paraly- 
sis of the velum may be bilateral or unilateral, the usual 
line of symptoms being present. The prognosis is not par- 
ticularly serious. Treatment should be directed to the relief 
of the exciting cause. 

Tumors, meningitis, cysts, or abscesses — tubercular or 
syphilitic — attacking the medulla, are usually slow in de- 
veloping, involve other structures whose centers are in prox- 
imity to the palatal, and produce a complicated line of symp- 
toms. The symptoms given under these headings describe 
only those of this region, and do not describe all that may 
-arise. 

Herpes of the Fauces. — Fortunately this is not often 
encountered, but it usually attacks the uvula and velum. 
There is more or less discomfort, occasionally actual pain 
and an annoying itching ascribed to the fauces. Inspection 
shows small purplish papules distinctly differentiated from 
the pink normal mucosa. Usually unilateral, either irregu- 
larly placed, or in circular form. The disease may disappear 
after five or ten days, reappearing after a variable time of 
weeks or months. The treatment should be to improve the 
general health, and locally some sedative application, as 
chloretone inhalant, used to relieve the most aggravating 
symptoms. 



CHAPTER XVII. 
DISEASES OF THE TONSILS. 

(i) Pharyngeal. (2) Faucial. (3) Lingual. (4) 
Laryngeal. 

Pharyngeal Tonsil. — Luschka's Tonsil. — This is situ- 
ated at the posterior wall of the pharyngeal vault, and is 
normally present in children. It usually atrophies between 
the ages of twelve and twenty, but when abnormal this may 
not occur. The surface is often lobulated. This structure 
comprises lymphatic or adenoid tissue held together by fine 
trabecular of connective tissue elements. It is practically 
a conglomerate gland, and is covered with a thin mucous 
membrane having a single layer of columniated epithelium, 
which occasionally is ciliated. Numerous follicles are con- 
tained in the gland and the vascular supply is abundant. 
In many cases this tissue involves the openings of the Eu- 
stachian tubes, and then we have the tubal tonsil. 

Faucial Tonsils. — These are two, contained in the 
spaces between the pillars of the fauces. They are lymphoid 
in character, and contain follicles and crypts. They are very 
vascular, and the mucous membrane covering is lined with 
squamous epithelium. 

Lingual Tonsils. — These comprise a series of lymphoid 
masses situated at the posterior one-fourth of the tongue. 

Laryngeal Tonsils. — These are small lymphoid masses 
or nodules located within the ventricle of the larynx, and 
are seen on inspection only when diseased. 

Inside the nasal openings, beneath the mucous membrane, 
diffuse adenoid tissue is present, but in some locations is in 
masses of lymph-follicles, designated as nasal tonsils. 

345 



346 Nose, Throat and Ear. 

Luschka's bursa consists of a crypt or depression located 
in the lower portion of the pharyngeal tonsil. 

Pharyngeal Tonsil. 

Synonyms. — Uuschka's tonsil ; adenoids ; adenoid vege- 
tations ; discrete tonsils. 

The pharyngeal tonsil is a normal gland from the aver- 
age age of three years to about fifteen or sixteen years, when 
atrophy usually occurs. No inconvenience is noticed unless 
the tissue becomes hypertrophied, when there is impeded 
nasal respiration. In some few cases the hypertrophy 
seemed to be congenital or occurred soon after birth. An 
early recognition of enlargement of Uuschka's tonsil is im- 
portant, as the normal development of the nasal structures 
and the palatal portion of the superior maxillary depends 
upon normal respiration. Not only is the bony portion in- 
fluenced, but the alse nasi and their muscles as well. 

If the disease is not recognized before the bony struc- 
tures are firmly united, operative measures will give only 
partial relief, and the patient may remain a confirmed mouth 
breather. The superior maxillary afch is usually abnormal, 
being highly arched, and the upper teeth are decidedly de- 
formed. The "inherited tendency" to adenoids is usually 
the family nose with its narrow openings and narrow nasal 
cavities. Unilateral obstruction may sometimes occur. 

Adenoids comprise not only hypertrophy of the pharyn- 
geal tonsil, but the closed follicles of the posterior and pos- 
tero-lateral walls of the nasopharynx. 

Etiology. — As a rule the morbid condition is not present 
before the age of three years, and it may become pronounced 
at any time before twelve years. Usually physiological 
atrophy should take place between the age of ten years and 
sixteen years. Sex is not a factor. Hereditary taints, gen- 
eral debility of the system, as well as the family nose may be 
factors. Climatic conditions, such as sudden changes of 



Pharyngeal IWsii,. 347 

temperature or an excessively damp atmosphere, are espe- 
cially favorable factors. Probably on account of irritating 
vapors the children in cities are more often affected than 
those living in the country. Purulent rhinitis or the infec- 
tious diseases may also be exciting factors. The uric acid 
diathesis is also accredited with being a cause. Disturb- 
ances of the alimentary canal, either disease or the irritation 
caused by intestinal parasites or undigested material will- 
cause turgescence of the nasal and nasopharyngeal tissue. 
Renal or pulmonary affections have been supposed to be 
exciting causes. 

Pathology. — Histologically the normal gland shows the 
same characteristic structure as other glands of the same 
type. The pathology varies, as there are practically four 
types. 

The soft variety is that of a smooth, semifluctuating mass, 
distributed over nearly the entire nasopharynx. Atmos- 
pheric changes and the general health of the patient influ- 
ence the condition. The growth is composed mostly of lym- 
phoid tissue, covered with a thin layer of epithelium, having 
an illy formed basement membrane and submucosa. This 
type is friable, being easily broken down with the finger. 

The edematous or cyanotic type is practically due to 
venous stasis and edema, without much increase of gland 
structure. This form is associated with either intestinal 
irritation or systemic circulatory wrongs. Children having 
intestinal worms are most frequently affected with this type. 
The growth is smooth and tense, but readily compressible. 

The hyperplastic or hard type has an increased amount 
of connective tissue elements, as well as an increase of lym- 
phoid material. The mucous membrane usually consists of 
several layers of epithelial cells. The surface is lobulated, 
but smooth to touch. 

There is another hard form which results from inflam- 
matory conditions of the lymphoid and connective tissue 



348 Nose, Throat and Ear. 

structures, followed by slight contraction. This form may 
be secondary to inflammatory action in the nose or naso- 
pharynx, or from the use of the thermo- or galvano-cautery. 
The appearance of these lesions varies according to the 
stage. In children it is usually impossible to get a view of 
the tissues by posterior rhinoscopy on account of the small 
nasopharynx. Examination with the finger is the only sure 
method in these cases. Frequently the gland tissue just back 
of the posterior faucial pillars is enlarged, and usually it is 
secondary to the hypertrophied pharyngeal tonsil. This lat- 




FiG. 78. Posterior rhinoscopic view in an adult showing hyper- 
plastic adenoid tissue and hypertrophy of the inferior turbinates. 

eral tissue nearly always disappears after the adenoid oper- 
ation. 

The so-called recurrent cases, after an operation, are 
generally the result of hypertrophy of tissue not removed, 
rather than a reformation at the original location. 

When hyperplastic or inflammatory changes have oc- 
curred in the pharyngeal tonsil, atrophy seldom takes place, 
so the tissue remains enlarged after the age for physiological 
atrophy, and may continue to adult life or even old age. 

Symptoms. — The clinical features do not vary particu- 



Pharyngeal Tonsil. 



349 



larly from those found in any nasal obstruction, only they 
are more pronounced, and permanent alteration of adjacent 
structures is more frequently seen. The expressionless face 
is quite characteristic. The prominent upper lip, chin reced- 
ing, bridge of the nose broadened, and the mouth usually 




Fig. 79. Vertical antero-posterior section through the post- 
nasal region in adolescence, showing enlargement of the pharyn- 
geal tonsil. (Zuckerkandl.) 

open, all imparting a stupid look to the patient which is 
almost always present. The child is usually unable to con- 
centrate its mind for any length of time. The hearing is 
generally impaired. There is an aversion to active sports, 
an irritable temper, sleep disturbed, and after a variable 
time a debilitated condition of the system. 



350 



Nose, Throat and Ear. 



Allen and Cohen attribute the mental inactivity as pos- 
sibly being due to lymphatic or circulatory changes between 
the brain and nasopharynx. Another explanation for this 
condition is the lack of ventilation to the frontal lobes of the 
brain through obstructed nasal respiration. If the postnasal 
obstruction is slight, there may be nasal respiration during 
waking hours, and mouth breathing only at night, the child 
simply complaining during the day of irritation in the throat, 
the exciting cause frequently being undetected. The usual 




Fig. 80. Typical facies in adenoids. 

symptoms of pharyngeal and laryngeal irritation will be 
noticed. The development of the physical system will also 
be retarded. 

The character of the voice is changed, the so-called 
"nasal twang" becoming more and more marked, the letters 
m, u, and ng being especially difficult to pronounce. Ear- 
ache and deafness are common symptoms. Epistaxis, most 
frequently at night, often occurs, but is not often profuse. 
If the growth extends well down in the nasopharynx, and 
the gland tissue of the lateral walls is enlarged, there is often 
difficulty in swallowing fluids, causing choking. 



Pharyngeal Tonsil. 351 

The faucial tonsils often become enlarged, the velum and 
uvula relaxed, and the glands at the angle of the jaw en- 
larged. Gastric complications are common. Frontal head- 
ache, eyes dull, and the conjunctiva often congested are fre- 
quent symptoms, the sense of smell and taste are usually im- 
paired. It is not often all of these symptoms are present in 
one case, but more or less of them will be noted. 

Diagnosis. — Usually not difficult, remembering the fades, 
irregularity of the teeth, and associated lesions of the ears, 
pharynx, and larynx. A digital examination will confirm 
the diagnosis. 

Prognosis. — This depends largely upon the time of rec- 
ognition of the disease. 

Treatment. — This depends largely upon the type of the 
obstruction, but prompt relief should always be given. If 
the enlargement is of the edematous form, the result of 
intestinal or gastric irritation, the removal of the irritation 
will generally give quick relief to the nasal symptoms. If 
there are cardiac wrongs, the proper remedies will also re- 
lieve the edematous condition. 

The soft variety can easily be crushed with the finger, 
and whether advisable to lacerate the tissue to any extent 
must be determined in each individual case. I believe it best 
to give enough general anesthesia to keep the child quiet. 
The operation in itself is not painful, but the child will be 
frightened more by the gagging produced than by the actual 
operation. Partial anesthesia is all that is required. There 
is not much hemorrhage in these cases, and the slight in- 
flammatory action following will soon subside with absorp- 
tion of the mass. The hands of the operator should, of 
course, be thoroughly cleansed before operating. 

In the hard varieties, operative measures only will give 
relief. The question of anesthesia must always be consid- 
ered. Individually, general anesthesia with chloroform is pre- 
ferred, the extent depending upon the amount of time likely 



352 



Nose, Throat and Ear. 



to be required. If the faucial tonsils are enlarged and re- 
quire removal, this should be done before the adenoid oper- 
ation. 

After the patient is anesthetized, the mouth gag should 
be placed in position, and the patient placed so the head will 




Fig. 8i. Denhardt's Mouth Gag. 

hang over the edge of the table, or if on an operating table, 
a modified Trendelenburg position may be used. The post- 
nasal space should be carefully examined with the index 
finger before attempting to operate. The curette is then in- 
troduced, using the index finger of the unoccupied hand as 
a guide. The curette at first should be carried into the naso- 
pharynx well forward toward the choanse, un+il far enough 




Fig. 82. Gottstein's Curette. 



up to engage the mass, then with a sweep of the blade bring 
away the tissue in the median line. The operation is re- 
peated on each side, always guiding the instrument and 
being careful not to injure the tissues about the openings 
of the Eustachian tubes. In some cases where the amount 
of tissue is small and high in the pharyngeal vault, the small 



Fauci al Tonsils. 353 

curette recommended by Kyle, using it through the nose 
and guiding as with the Gottstein curette, can be used to 
advantage. 

There is little danger of secondary hemorrhage, except- 
ing where there are anomalous vessels, or the patient is a 
bleeder. If a persistent hemorrhage does occur, the naso- 
pharynx may be packed with gauze or cotton tampons until 
the bleeding stops. 

In the majority of cases no local after treatment is em- 
ployed. The patient is usually kept quiet for a few days, 
and usually hydrastis and phytolacca are given internally. 
If local measures are necessary, an alkaline wash is used. 

Faucial Tonsils. 

Inflammatory Diseases. 

(1) Acute, (a) Acute Superficial, (b) Cryptic, (c) 
Rheumatic or Gouty, (d) Herpetic, (e) Tonsillar and 
Peritonsillar Abscess. (f) Membranous Inflammation. 

(2) Chronic, (a) Enlargement or Hypertrophy, (b) 
Caseous, (c) Chronic Abscess, (d) Atrophy, (e) My- 
cosis. 

(3) Foreign Bodies. 

The faucial tonsils are practically lymphatic glands. On 
account of the structure and exposed position, the patholog- 
ical changes are important. The glands may be involved 
either from local conditions, or secondarily through systemic 
lesions. Superficial ulceration of the tonsil may be a cause 
of systemic infection. Primary infection may be associated 
with pharyngeal or laryngeal lesions, as in the infective 
fevers or exanthemata. In rheumatic or gouty conditions, 
or intestinal wrongs where autointoxication results, local 
manifestations in the tonsils may occur. Anemic conditions 
are liable to cause changes in the lymphoid structure of the 
tonsil. Ulceration often results in any inflammation of the 
gland. 
23 



354 Nose, Throat and Ear. 

Acute Superficial Tonsillitis. 

Synonyms. — Acute catarrhal tonsillitis ; Tonsillitis ; 
Acute catarrhal angina. 

This is an acute inflammation of the tonsillar mucous 
membrane, and may invade the crypts and parenchyma. It 
may extend to, or be caused by, inflammatory action of con- 
tiguous structures. 

Etiology. — This condition is most often seen in children 
and young persons. This is probably because the lymphoid 
tissue is most highly developed at this period, as later in life 
atrophy usually occurs. Sudden changes in the temperature 
or exposure are frequent causes. Injury of the tonsils or 
adjacent tissues may also be a cause, also irritation from 
acrid fumes or vapors, scalds, or inhalation of steam. Mouth 
breathing may be a predisposing factor. Lowered vitality 
from any cause may be an important factor. 

Pathology. — Practically that of any catarrhal inflamma- 
tion of mucous tissue surfaces. 

Symptoms. — These vary in intensity. Usually there is a 
feeling of malaise, some headache; stiffness of the muscles 
of the neck, and a slight chill followed by fever. Slight 
pain on swallowing and a sensation of fullness is also pres- 
ent; later the pain may be continuous, but is always in- 
creased on swallowing. If neglected, motion of the head 
and neck will be painful, or even torticollis may occur. In- 
spection shows a deep red color, with an edematous appear- 
ance. The soft palate, uvula, and faucial pillars are also 
implicated. As the process continues, the crypts are filled 
with serum and • fibrin resembling patches of membrane. 
Tinnitus and pain in the ear may be complained of. There 
may be hoarseness due to change in the circulation of the 
epiglottic region or vestibule of the larynx. Nasal reso- 
nance is also often faulty through the swelling of the uvula 
and velum. In young children the symptoms are often more 



Cryptic Tonsiwjtis. • 355 

marked, and the attack rapid in development. Recurrence 
is the rule, and as a result there is a decided enlargement of 
the tonsil. Glandular involvement is the exception. 

Diagnosis. — The disease is often bilateral. The rapid 
progress and absence of adherent membrane on the tonsil 
or surrounding structures will aid in the diagnosis. 

Prognosis. — Good. Recurrence may be prevented in 
the majority of cases by proper measures. 

Complications. — In some cases owing to congestion of 
the laryngeal structures, there may be relaxation of the vocal 
cords. The loss of voice may occur after the acute attack. 
Catarrhal or purulent otitis media may follow. Elongation 
of the uvula may result from the relaxation of the velum. 

Treatment. — These cases usually recover rapidly if 
proper medication is employed. Local measures are not of 
much use. Unless contraindicated, a saline cathartic is bene- 
ficial in the majority of cases. Internal medication. When 
the pain on swallowing is very severe, the drugs may be used 
either with an atomizer or in concentrated solution, thus 
relieving the necessity for swallowing. Aconite combined 
with phytolacca will usually afford prompt relief. Eating 
ice-cream often relieves much of the congestion, and is not 
only a food, but a medicine as well. In some cases hot 
drinks will be desired. The direction usually given, to use 
a gargle, is cruel. It not only increases the congestion, but, 
what is most important is the fluid seldom comes in contact 
with the inflamed structures. The atomizer is more useful 
and does not increase the congestion. Steam is sometimes 
beneficial, and can be medicated. 

Cryptic Tonsillitis. 

Synonyms. — Lacunar Tonsillitis. Follicular Tonsillitis. 

This type differs from the superficial only in the amount 
of tissue affected. There may be only a few of the crypts, 
or the entire tonsil may be implicated. When the deeper 



356 Nose, Throat an© Ear. 

structures are involved, affecting the entire gland, it is 
termed parenchymatous tonsillitis. 

Etiology. — The liability to this type is much increased 
by the anatomical structure. The deep crypts with small 
openings favor the accumulation and retention of the secre- 
tions sufficiently to cause irritation of the crypt walls ; this, 
with decomposition of the material, forms a nidus for infec- 
tion. A vitality lowered from any cause is also a predis- 
posing factor. Climatic changes are important in producing 
the disease. The disease is found most frequently between 
the ages of ten and thirty years. 

Pathology. — The tonsillar enlargement is the result of 
vascular engorgement, accumulated secretion, and inflam- 
matory exudate within the crypts, as well as into the paren- 
chyma itself. This exudate being serous, accounts both for 
the edematous condition and the infiltration of the migrated 
leukocytes. The exudate on the surface separates as fibrin 
and serum. The most of the fibrin may be deposited in the 
crypts, giving the impression of membrane formation, while 
it is only the retained inflammatory exudate. Infection 
through the crypts and also from the impeded blood-supply 
to the inflamed area may cause the tissue to undergo lique- 
faction-necrosis and abscess-formation. 

Symptoms. — Pain is a constant, characteristic symptom. 
Motion, either on opening the mouth or on swallowing, in- 
creases the pain. Sharp neuralgic pain, passing to the ear 
and to the cervical region, is often complained of. The 
quality of the voice is changed. Normal respiration is not 
often impeded, unless the postpharyngeal tissues are in- 
volved. An irritating cough, reflex in character, through 
inflammatory pressure on the phrenic and recurrent laryn- 
geal nerves, may be present. The effort to clear the throat 
is almost constant. The disease is usually unilateral. The 
increase of pain on swallowing is due to muscular spasm 
and diminished size of the faucial opening. The pain is 



Cryptic Tonsillitis. 357 

usually referred to the temporomaxillary articulation. In 
many cases it is almost impossible to swallow either liquids 
or solids, and often w r hen the effort is made there will be 
regurgitation of the material. Through extension of the in- 
flammation to the vault of the pharynx, the Eustachian tubes 
may become affected, thus causing middle ear disease. 

Inspection of the tonsil is often difficult on account of 
the patient not being able to open the mouth. When pos- 
sible to get a good view, the surface of the tonsil appears 
deeply reddened and edematous, with whitish or yellowish 




Fig. 83. Cryptic or Follicular Tonsillitis. 

points indicating the orifices of the crypts. When there is 
a profuse inflammatory exudate, there is a serofibrinous ma- 
terial, more or less covering the surface, which has a resem- 
blance to membranous inflammation. The febrile symptoms 
vary considerably. As a rule there is increased temperature, 
skin dry and warm, and more or less nausea. As the disease 
progresses, and if suppuration occurs, there will be chills, 
the skin clammy, mental dullness, face pallid and with an 
anxious expression. The tongue is heavily coated, usually 
a pasty or dirty colored coating, and the breath is peculiarly 
offensive. Thirst is a constant and annoying feature. The 
usual clinical symptoms of inflammatory action are noted 



358 Nose, Throa* and Ea&. 

in this form of tonsillitis. Constipation, scanty, high-colored 
urine, with an excess of urea and urates, and occasionally a 
small amount of albumin. The glands at the angle of the 
jaw may be enlarged, but usually not in the early stages. 

Diagnosis. — The severity of the symptoms as well as the 
appearance of the tonsil, will differentiate from the super- 
ficial variety. 

Prognosis.— Good. When seen early it is seldom that 
suppuration occurs. 

Treatment. — Will not vary from that already given 
under acute superficial tonsillitis, excepting more attention 
to the activity of the excretory functions is required. The 
use of the atomizer or concentrated medicines will be appre- 
ciated by the patient. The medicine should be given fre- 
quently until there is an improvement in the condition. In 
some cases it will be necessary to evacuate the crypts, but 
often the case is seen too late to do this, and it is better to 
wait until the acute symptoms have subsided, rather than 
torture the patient by forcing the mouth open. 

Rheumatic or Gouty Tonsillitis. 

Whether the uric acid diathesis is a factor in producing 
this form of tonsillitis is a question, but that infectious ma- 
terial in the system, from any cause, is liable to infect the 
lymphatic system, and especially the faucial tonsils, is un- 
questionably true. Any portion of the tonsil may be in- 
volved. Usually there is a history of repeated attacks of 
acute tonsillitis, varying in severity. Rheumatic constitu- 
tional symptoms may or may not coexist. Acute exacer- 
bations occur, but the irritation is constant and the inflam- 
matory process is usually slow. Both tonsils are often 
affected and are enlarged and irregular, almost meeting in 
the median line. This condition interferes with normal res- 
piration and nasal resonance. The voice is thick and 
muffled, there is an annoying accumulation of secretion in 



Herpetic TonsiIuTis. 359 

the throat, and the breath is offensive through the retention 
of decomposing material in the tonsillar crypts. There is 
often regurgitation of fluids and food into the nasopharynx 
on attempting to swallow. The symptoms and pathology do 
not vary particularly from the other varieties of tonsillitis. 
Connective tissue changes in the tonsils usually follow re- 
peated attacks, and the tonsil will be firm and hard to touch. 

Diagnosis. — It is difficult to differentiate on inspection, 
although usually there is a peculiar appearance of the blood 
stasis, which is not often found in the other varieties, but 
this is difficult to describe. There is also a more or less 
bruised sensation of the pharyngeal tissues, independent of 
the soreness, which is lacking in the other varieties. The 
history of a rhemuatic or gouty tendency will also be an aid. 
Whether or not future experience will substantiate the uric 
acid diathesis as the principal factor remains to be seen. 

Prognosis. — Favorable. 

Treatment. — The eliminative functions must be kept 
active. For the constipation which usually is present, rham- 
nus Californica. With an edematous condition of the tis- 
sues, apis or apocynum. In some cases when the tongue is 
pallid and coated with a light pasty fur, or the coating is 
dirty, urine scanty, and with a dull headache, potassium 
acetate will be indicated. When there is a bruised sensation 
of the pharyngeal tissues, cimicifuga. Besides these reme- 
dies, those given under acute superficial tonsillitis are often 
indicated during an acute attack. For the chronic condition, 
in addition to the hygienic and eliminative measures, Phyto- 
lacca should be given for its influence on the glandular sys- 
tem, and iris should be combined with it if the lymphatic 
circulation is sluggish. 

Herpetic Tonsillitis. 

In this variety herpetic vesicles on the tonsil are associ- 
ated with an acute pharyngitis. 



360 Nose, Throat and Ear. 

Etiology. — As a rule this condition occurs in persons 
whose power of resistance is weakened. Anemic conditions 
also seem to favor its development. Cold or exposure are 
the most frequent exciting causes. 

Pathology. — The vesicle has a bleb-like appearance, and 
is filled with a fluid or semi-fluid material. The outer wall 
of the vesicle consists of a thin layer of mucous membrane. 
Sometimes a false membrane is formed over the mucous sur- 
face, the result of fibrinous exudate and coagulation necrosis 
of the epithelium. 

Symptoms. — The condition develops rapidly, temperature 
generally high, marked chills, aching pains referred to the 
bones, anorexia, severe headache, tongue heavily coated, and 
nausea. The pharyngeal and faucial regions are painful, 
and present a decidedly red color on inspection. The minute 
vesicles repeatedly occur on both the pharyngeal and ton- 
sillar surfaces. In the early stages they are discrete, but 
after twenty-four hours may become confluent, forming 
large blebs. After twenty-four or forty-eight hours the 
vesicles usually open, leaving whitish ulcers. The glands 
are not often affected. After three or four days the lesions 
generally entirely disappear. 

Diagnosis. — Inspection and the history of the case will 
determine the character of the disease. 

Prognosis. — Good. There is a tendency to recurrence, 
however. 

Treatment. — The use of rhus will usually relieve the 
burning sensation. Local applications are of little benefit. 
Systemic improvement must be relied upon to effect a cure. 

Tonsillar and Peritonsillar Abscess. 

Synonyms. — Peritonsillar Phlegmon ; Phlegmonous Ton- 
sillitis ; Quinsy. 

It is not often that a suppurative inflammation is" limited 
to the faucial tonsil, the peritonsillar tissue usually being the 



Tonsillar and Peritonsillar Abscess. 361 

structure involved. The disease may result from infection 
through the tonsil, following or accompanying some inflam- 
matory action of the tonsil or its contiguous structure. In 
many cases the lesion is the result of, or associated with 
some constitutional septic condition, or to infected emboli. 
The infectious fevers often Tiave peritonsillar abscess as an 
accompaniment. 

Etiology. — Infection may be present from the inception 
of the disease, or it may be secondary to any of the varieties 
of inflammation of this region. Lessened physiological re- 
sistance of the mucous membrane will increase the liability 
to infection. The exact relation of the buccal bacteria to 
the process is undetermined, but probably they are simply 
subordinate factors. 

Pathology. — The morbid changes are the same as found 
in inflammatory action of mucous membrane surfaces. The 
gland is held and nourished only at the external side, and 
for this reason rapid engorgement is favored. The lym- 
phatic channels afford an easy and rapid spread of inflam- 
matory products, which accounts for the usual implication 
of the cervical and sublingual lymphatics. The contiguous 
connective tissue is early infiltrated with embryonal cells. 
There is considerable edema both internally and externally, 
as a result of the impeded lymphatic circulation. As a re- 
sult of lack of nutrition, coagulation-necrosis follows at a 
point remote from the blood supply, which is in the tonsillar 
or peritonsillar tissue, an abscess forming. The process is 
the same as in any abscess formation. There is more tend- 
ency to extension of the abscess when the point is back of 
the tonsil or in the peritonsillar structure, than when in the 
tonsil itself. When in the latter tissue a spontaneous rup- 
ture will generally be at the lowest part of the gland, open- 
ing directly into the pharynx. When the abscess is in the 
peritonsillar tissue, the line of least resistance is usually fol- 
lowed, which may be anterior or posterior, following along 



362 Nose, Throat and Ear. 

the muscles toward the larynx. These cases may require 
an incision penetrating the entire tonsillar structure. 

Symptoms. — The symptoms of tonsillar and peritonsillar 
abscess are similar, but vary somewhat in intensity. Before 
pus is formed, the symptoms are practically those of acute 
catarrhal or lacunar tonsillitis. * This may continue two or 
four days. Sometimes there is an apparent improvement, 
when suddenly a recurrence of the symptoms occurs. There 
is restlessness and fever, abnormal secretion, mouth dry, 
appetite impaired, constipation, and scanty urine. Pain in 
the tonsillar region is continuous, and radiates to the ear and 




Fig. 84. Tonsillar abscess of left tonsil. 

larynx. Motion of the head or swallowing increases the 
p&in. The pillars of the fauces, and often the velum and 
uvula, as well as the pharyngeal and laryngeal tissues, are 
red and edematous. Edema of the glottis sometimes results. 
If suppuration ensues, the symptoms are all aggravated, 
the swelling of the tissues increased, and swallowing is a 
positive torture. It is almost impossible for the patient to 
open the mouth, somewhat simulating lockjaw. External 
pressure at the angle of the jaw causes intense pain, while 
tenderness is constantly present. Sometimes at the com- 
mencement of the attack there is rigor, followed by several 
chills. The breath is offensive, and the tongue coated with 



Tonsillar and Peritonsillar Abscess. 363 

a brownish, dirty fur. The severity of the symptoms do not 
always depend upon the amount of pus formed. Spon- 
taneous rupture may take place at the lower portion of the 
gland, or in severe and infected cases necrosis and partial 
sloughing of the tonsil may follow. Usually operative meas- 
ures are instituted before such a result occurs. In some 
cases ulceration may follow the suppuration, but not often. 
The symptoms are less severe in tonsillar than in periton- 
sillar abscess. Glandular implication and external swelling 
is less. Often there are numerous small abscesses instead 
of one. The abscesses may be deep-seated or close to the 
surface, and may require opening, or may rupture spon- 
taneously. It is often impossible to detect fluctuation. If 
the disease occurs as a complication of measles, scarlet fever, 
typhoid fever, or influenza^ the progress is slower and gen- 
erally more serious. The disease is most often unilateral. 

Complications. — Serious complications seldom arise, but 
the abscess may spread, following the line of least resist- 
ance, into the deeper cervical tissues, and pointing exter- 
nally. Edema of the glottis is to be feared when there is 
much watery' exudate into the intercellular spaces. Middle 
ear disease may result by extension of the inflammatory proc- 
ess into the nasopharynx, affecting the Eustachian tubes. 
When there is extensive necrosis in a deep-seated abscess, 
there is a possibility of involvement of the internal carotid, 
or thrombosis of the jugular veins. Thickening of some 
portions of the tonsil and contraction at the site of the ab- 
scess, may form a lobulated irregular gland. Adhesions 
between the tonsil and faucial pillars usually result. 

Diagnosis. — The clinical symptoms, previous history, in- 
spection when possible, and the peculiarly offensive breath 
should make a diagnosis comparatively easy. 

Prognosis. — Usually favorable. 

Treatment. — The treatment already given will prove suc- 
cessful in the majority of cases, if seen before suppuration 



364 Nose, Throa* and Ear. 

has commenced. After the formation of an abscess, how- 
ever, incision is necessary. When possible to locate the ab- 
scess, there is but little difficulty in obtaining drainage. A 
curved bistoury may be used or a tenotomy knife. When 
the former, the blade should be protected with adhesive 
plaster, excepting the actual cutting portion. When the in- 
cision is made, the direction of the cut should be toward the 
pharynx, to avoid anomalous vessels. 

Membranous Inflammation of the Tonsil. 

Synonyms. — Membranous tonsillitis ; Fibrinous tonsil- 
litis. 

Different conditions of infection may occur in which 
membrane closely resembling diphtheritic membrane will 
form, either on the surface or within the crypts. In many 
cases the caseous material in the crypts and extending to the 
orifices will be seen as localized membranous inflammation. 
In streptococcal infection, membrane is often found on the 
faucial pillars, tonsil, and wall of pharynx. In disturbances 
of the alimentary canal the pharyngeal and faucial mem- 
brane is frequently reddened, inflamed, and small mem- 
branous patches are seen. After the use of the cautery, 
escharotics, or tonsillotomy, membrane may form. 

Pathology. — This is practically the same as is found in 
infection with the Klebs-Loffler bacillus. The bacteria pres- 
ent are really of secondary importance. The exciting fac- 
tors of the disease have been given. Localized ulcers may 
form, giving the so-called ulcerative tonsillitis, which is quite 
noticeable when the crypts are invaded. 

Symptoms. — Seldom very intense. The glands of the 
neck may be enlarged through infection of the lymphatics. 
Pain in the tonsil is constant, and is increased on swallow- 
ing, the breath is offensive, the voice more or less impaired 
through extension of the inflammatory action. Pharyngeal 
inflammation and occasionally an abscess may form through 



Enlargement of the Tonsii*. 365 

infection, although when the case is seen early, complica- 
tions are infrequent. 

Treatment. — Besides what has already been given, po- 
tassium bichromate internally will be useful. A three per 
cent solution of this drug may also be beneficial used as a 
spray. 

Enlargement or Hypertrophy of the Tonsil. 

Synonyms. — Hyperplastic Tonsillitis ; Hypertrophic Ton- 
sillitis. 

Two varieties of enlarged tonsils occur. In one type 
the structure is soft, the increase in size being due largely 
to glandular material. In the second type the structure is 
hard, there being more connective tissue increase, although 
glandular tissue may also be increased. It is necessary to 
remember that simply an enlarged tonsil does not always 
mean a hypertrophied condition, as the enlargement may 
be the result of vascular conditions, venous stasis, or an 
edematous state of the tonsil. In children the tonsils are 
normally large, and there is also gland tissue outside the 
faucial pillars, and the condition does not necessarily denote 
a morbid condition. Hypertrophy is often applied in cases 
which are only inflammatory or hyperplastic. 

Etiology. — Increase in size of the tonsils may be due to 
a variety of causes. Inherited taints seem to predispose or 
actually cause such changes. A chronic inflammatory con- 
dition as in gouty, rheumatic, or the so-called uric acid dia- 
thesis, is a common factor. Sex does not seem to have any 
influence. Lesions of the throat are prolific causes. Climate 
also influences changes of the tonsils and throat. Lowered 
vitality, the result of specific inflammation, as well as the 
acute infectious diseases of children, often cause permanent 
enlargement. Cardiac, pulmonary, hepatic, renal, or intes- 
tinal lesions, when causing obstruction to the venous flow, 
may cause enlargement of the gland. In these cases there 



366 Nose, Throat and Bar. 

is cyanosis of the mucous membranes. The tonsil is soft 
and boggy, as a result of watery or serous infiltration into 
the tissues and a slow chronic inflammatory change. In re- 
peated tonsillar or peritonsillar abscess, the enlargement is 
an inflammatory increase in the connective tissue. 

Pathology. — In the soft variety, the glandular element 
predominates, fine trabecular of connective tissue supporting 
the clusters of glands. The structures are the same as in 
the normal tonsil, unless there has been a decided chronic 
inflammatory condition, when there may be considerable in- 
crease of connective tissue. The fibrous character in these 
cases is probably due to the organization of inflammatory 
material. Where the tonsil is decidedly lobulated, the con- 
nective tissue is fibrous, the crypts are deeper, more irreg- 
ular, and their openings contracted. When the connective 
tissue is largely hyperplastic, the gland is less irregular, 
there is less contraction, and the crypts less saccular and not 
so liable to retain caseous material. When the tonsil is en- 
larged through a chronic irritation, the thickening is more 
regular in all the gland structure. If the result of repeated 
imflammatory lesions, it is irregularly fibrous, and after con- 
traction is lobulated. Climatic conditions and derangements 
of the vascular system influence the soft variety. The soft 
and hyperplastic forms usually atrophy in adult life. When 
the enlargement is the result of inflammatory action, atrophy 
less often occurs, although some diminution in size may take 
place. This form is frequently associated with inflammatory 
lesions in adjacent structures, the most frequent being ad- 
hesions between the tonsils and pillars of the fauces, espe- 
cially the anterior. These adhesions often provoke as annoy- 
ing symptoms as the enlarged tonsil. This condition usually 
reveals the tonsil as a hard fibrous mass, and with the ad- 
hesions there is a constant irritation, causing symptoms 
similar to chronic pharyngitis. Glandular enlargement in 
the velum and faucial pillars will be present. 



Enlargement of the Tonsil. 367 

Symptoms. — The glands may be so enlarged as to almost 
touch, and some cases have been reported where they have 
actually met and become adherent from ulceration. Normal 
respiration is impeded, the mobility of the uvula impaired, 
and regurgitation of fluids and food often occurs on swal- 
lowing. The openings of the Eustachian tubes may be af- 
fected, either by pressure or extension of the inflammatory 
process. Laryngeal and pharyngeal irritation results, in the 
majority of cases, through mouth breathing. The facies is 
similar, but not so marked, as in adenoid hypertrophy. Rest- 
lessness at night, and a hacking, rasping cough is often 
present. Adenoid hypertrophy is often associated with ton- 
sillar enlargement, when all the symptoms are accentuated. 
Systemic derangements are usually very noticeable ; anemia, 
languor, and subnormal mental and physical states. There 
is the nasal twang to the voice, and imperfect phonation. 
Middle ear lesions are frequently present. In children es- 
pecially, deglutition is faulty. Adhesions' of the tonsils to 
the faucial pillars is nearly always a complication. These 
adhesions being of inflammatory origin, and contraction fol- 
lowing, the gross appearance of the tonsils will be changed. 
More discomfort often results than in an actual inflamma- 
tory state. The* sensation of a foreign body in the throat, 
frequently associated with gastric disturbances and nausea, 
are often complained of. Bronchial and asthmatic cough 
may be present as reflex conditions. The recumbent po- 
sition often increases the annoyance. 

Diagnosis. — Easy, inspection revealing the condition. 
Digital examination will determine the character of the en- 
largement. 

Progn osis. — Good. 

Treatment. — The treatment will depend upon the char- 
acter of the glands, and resolves itself into medical or 
surgical. In children and young adults the tonsils are 
usually large, and unless there are irritative symptoms, or 



368 Nose, Throat and Ear. 

interference with phonation or swallowing, no radical treat- 
ment is necessary. In advanced years the same rule holds 
good. When the tonsils are soft in character, internal medi- 
cation will usually have an influence in reducing their size. 
If due to circulatory wrongs, the treatment must be directed 
to this lesion. When the enlargement is lymphoid in char- 
acter, phytolacca or iris is most generally indicated, but the 
drugs must be used for some time to get results. In the 
fibriod types medication, either local or internal, is of little 
use. When the tonsil is enlarged, smooth, and regular, a 
small portion removed by the tonsillotome will usually suf- 
fice, on account of the contraction following. When irreg- 
ular, nodular, and pedunculated, the irregular portion may 
be removed by the tonsillotome or Kyle's curved scissors, 
or any of the instruments devised for this purpose. Local 



Mm* WOGME" & SON. C1N..O. 

FlG. 85. Douglas' Tonsil Knife. 

applications of drugs are of little use. The cold wire snare 
or galvano-cautery snare are not as generally applicable as 
the tonsillotome. Before using a tonsillotome the presence 
of adhesions should be determined by a careful examination, 
using a curved probe or blunt hook for the purpose. When 
adhesions are present, they should be divided before attempt- 
ing to use the tonsillotome. The tonsillotome should not be 
too sharp, but sharp enough to cut through the tissues with- 
out dragging on the gland. When the edge of the instru- 
ment is right, there is but little annoyance from hemorrhage, 
excepting in the case of bleeders. With such, or where 
anomalous vessels are present, it is not advisable to operate. 
Cutting too deeply into the structures, especially when a 
bistoury is used, might be followed by severe hemorrhage. 
In such cases the stump may have to be ligated, or a tonsil 
clamp may be required. In children the danger of hemor- 



Caseous Tonsillitis. 369 

rhage is less than in adults, although as a rule there will 
be profuse bleeding for a few minutes after the operation. 
In cases of persistent oozing, Lloyd's ergot or carbo veg. iX 
may be given. Secondary hemorrhage sometimes occurs, 
but the danger is materially lessened when no constringing 
drugs have been employed. The use of cocaine or the 
suprarenal products is to be condemned in these cases, as 
they unquestionably increase the danger of secondary hemor- 
rhage. In many cases the adhesions resulting from inflam- 
matory action not only cause a sensation of constriction, 
but a distinct discomfort on swallowing, and also a change 
in the character of the voice. Not infrequently these ad- 
hesions cause the tonsil to be unduly prominent. The di- 
vision of the bands will often afford relief without removal 
of the gland. 

Caseous Tonsillitis. 
This is practically an inflammation due to mechanical 
irritation. It may result from repeated inflammatory at- 
tacks, or from an enlarged tonsil with increased -depth of 
the crypts which have been changed by the morbid process, 
and pockets resulting scattered through the tonsil, most 
frequently in the lower portion. At times pockets may be 
found in the upper portion of the gland. Food and secre- 
tions accumulate in these pockets, and acting as foreign 
bodies, as well as through decomposition, produce inflam- 
matory action in the surrounding tissue. The history given 
in these cases is usually of repeated attacks of sore throat, 
a pricking sensation in the tonsil, and occasionally the es- 
cape of small particles of offensive smelling caseous material. 
Sometimes the patient is able to express this material, but 
frequently the material is retained by constriction or occlu- 
sion of the mouths of the pockets. In some cases the orifice 
closes, retaining the mass, which is noticed on inspection 
as a grayish-white nodule. Ptancture of this nodule will 
allow the escape of an offensive semi-fluid material. An 
24 



37° Nose, Throat and Ear. 

excess of lime salts may also form a calculus in these pock- 
ets. This is termed a tonsillolith or amygdalolith. A pocket 
may be formed at the base of the tonsil by adhesion with the 
anterior pillar. 

Treatment. — A free incision of the pocket from base to 
orifice. The use of a solution of Lloyd's Salicylic acid, 
gr. xx to Alcohol gj. should be made to each pocket, or 
95 per cent carbolic acid. The internal use of Phytolacca 
will aid in many cases through its action on the gland tissue,. 

Chronic Abscess of the Tonsil. — But few cases have 
been reported. Kyle is inclined to believe from cases he has 
seen that the condition is the result of a caseous crypt, and 
not pyogenic. 

Treatment. — Incision, curettement, and cauterization of 
the surface. 

Atrophy of the Tonsil. — Neither physiological nor 
pathological atrophy lead, as a rule, to any discomfort. In 
one case, however, through adhesions and diminished blood 
supply following morbid atrophy, it was necessary to re- 
move the atrophied glands to give relief from annoying re- 
flex symptoms. 

Mycosis of the Tonsil. 

This is frequently caused by the Leptothrix buccalis 
affecting the outer layer of epithelium, occasionally within 
the crypts, but oftener about their orifices. Yellowish or 
yellowish-white spots indicate the affected areas. The af- 
fection is in reality a coagulation or liquefaction necrosis 
of the outer layer of epithelium. The pillars of the fauces, 
the pharyngeal membrane, and the base of the tongue are 
often similarly affected through extension. 

Disturbances of the alimentary canal, especially the 
stomach, may be a factor. 

Symptoms. — Usually the condition is discovered acci- 
dentally, but in some cases there is a pricking sensation. 



LlNGUAI. ToNSIIr. 371 

Diagnosis. — The appearance and microscopic examina- 
tion. 

Prognosis. — Good, but persistency in treatment is neces- 
sary, as it is likely to recur. 

Treatment. — Carious teeth should receive attention, as 
well as any alimentary disturbances. The use of the sali- 
cylic acid wash locally will be found beneficial, and inter- 
nally the administration of phytolacca or iris, but treatment 
must be continued for a long time. 

Foreign Bodies. 

Any sharp-pointed foreign body may become entangled 
or imbedded in the tonsil, especially if it is enlarged. 

Symptoms. — The same as a foreign body in the pharynx 
or at the base of the tongue. 

Inspection will usually reveal the foreign body, but care 
must be used in the examination, or gagging may cause 
the offending body to be concealed by the faucial pillars. In 
some cases the object may be so deeply imbedded that only 
by digital examination can it be found. 

Lingual Tonsil. 

(1) Acute Inflammation (Preglottic Tonsillitis). (2) 
Acute Phlegmonous Inflammation (Abscess). (3) Hyper- 
plasia. (4) Mycosis. (5) Varices. (a) Regular Dila- 
tation, (b) Saccular Dilatation, (c) Idiopathic Hemor- 
rhage. 

Synonyms. — Buccal Tonsil; Fourth Tonsil. 

Back of the circumvallate papillae and above the epi- 
glottic attachment, a number of rounded elevations are lo- 
cated. These masses are adeniod tissue, the lingual tonsil. 
In the center of each mass is a small orifice leading into a 
central crypt lined with stratified pavement epithelium, and 
surrounded by adenoid tissue supported by the connective 
tissue elements of the part. At the bottom of each crypt 
is the opening of a duct of a mucous gland. 



372 Nose, Throat and Ear. 

The lingual tonsil is important both physiologically and 
pathologically. Owing to its location, it has a close vascular 
and lymphatic connection with the tongue, upper portion of 
the larynx, pillars of the fauces, and lateral pharyngeal 
walls. As a rule, there are from ten to twenty of these 
modified racemose masses. The location renders the tonsil 
peculiarly liable to irritation in swallowing, and also there 




yr% cy 



Fig. 86. Hypertrophied adenoid tissue in the glosso 
epiglottic fossae. 

is the same tendency to morbid changes as is found in other 
gland tissue. 

Acute Inflammation. 

Synonym. — Preglottic Tonsillitis. 

Etiology. — An acute or chronic inflammatory process is 
the most frequent in this gland, being secondary to a sys- 
temic condition. It may accompany or follow the infectious 
fevers, tubercular or syphilitic conditions. In influenza, 
especially when the upper air passages are most affected, an 
inflammatory state often continues. Wrongs of the ali- 
mentary canal and autointoxication are often factors. Irri- 
tating smells or vapors may also have an influence. 

Pathology. — The changes are practically those of simple 
acute or chronic inflammation. The mass is swollen, edem- 
atous, and is readily seen either by direct inspection or by 
means of the laryngoscope. The gland may sometimes be 



Acute Phlegmonous Inflammation. 373 

affected by inflammatory action of adjacent or surround- 
ing tissues. 

Symptoms. — The secretion is excessive, and there is a 
constant desire to clear the throat. Even after the mem- 
brane is cleared of secretion, there is a sensation of a foreign 
body remaining. The patient frequently complains of the 
sensation of ""swallowing over something.'' The use of the 
voice often causes aching of the throat and a roughness or 
hoarseness which is due to excessive secretion and the asso- 
ciated inflammatory action about the larynx. A persistent 
hacking cough may also be present. The sense of taste 
may be impaired or entirely lost. The sublingual glands 
and those at the angle of the jaw may be slightly enlarged. 

When the nasopharyngeal tissues are involved in a gen- 
eral catarrhal condition and the uvula relaxed or elongated, 
the latter structure may come in contact with the epiglottis 
or lingual tonsil, and be the cause of constant irritation and 
a hacking cough. 

Diagnosis. — The laryngoscopy mirror will show the 
prominent masses and retained secretion. 

Prognosis. — Good. 

Treatment. — The primary cause must be corrected. For 
the local lesion, phytolacca and hydrastis or potassium bi- 
chromate are indicated. Locally, the use of the salicylic 
acid wash will be found beneficial in clearing away the se- 
cretion, and also in stimulating the glands to normal ac- 
tivity. 

Acute Phlegmonous Inflammation. 

This may be a primary condition, either associated with 
phlegmonous lesions of contiguous structures, or resulting 
from a mechanical injury. Usually the entire tonsil is im- 
plicated. 

Symptoms. — General febrile symptoms are present. 
There is pain localized in the region of the hyoid bone, and 
on one or both sides. There is considerable pain on attempt- 



374 Nose, Throat and Ear. 

ing to swallow, and also much difficulty in swallowing. 
The pain usually extends to the ear. There is little if any 
difficulty in opening the mouth, but protrusion of the tongue 
increases the pain. Hypersecretion is usually marked. 
Edema of the glottis may be threatened in severe cases. 

Diagnosis. — By digital examination and the laryngo- 
scope. 

Treatment. — If recognized early, an incision should be 
made, but the abscess usually ruptures spontaneously. 

Hyperplasia. 

Infrequently seen, but may accompany chronic inflam- 
matory conditions of the pharynx. 




MAX WOCHER & SON, OIN..O. 




Fig. 87. Lingual Tonsillotome. 

Symptoms. — Similar to those of acute inflammation, but 
with freedom from pain. There is often a sensation of a 
foreign body which may be on either side of or at the center 
of the hyoid bone. Eating or drinking causes disappearance 
of the symptoms, but use of the voice increases them. 

Diagnosis. — The laryngoscopic or digital examination 
will determine the condition. 

Treatment. — Very light cauterization with the galvano- 
cautery is the best method for this condition. The knife 
must be used cautiously. Twenty per cent chromic acid 
may be used every fourth or fifty day, being careful not to 
use an excess of the solution. 



Varices. 375 

Mycosis of the Lingual Tonsil. 

This is an inflammatory condition, the result of local 
infection with the Leptothrix buccalis. Small yellowish 
projections are seen under the tonsil which resemble mold. 
Ulceration seldom occurs. 

Treatment. — The salicylic acid solution used as a mouth 
wash, or a solution of asepsin. The alimentary canal will 
usually have to be treated, as digestive wrongs aggravate 
the condition. Locally the use of iodine, touching the af- 
fected areas will be required. Occasionally the galvano- 
cautery may be needed. 

Varices. 

The veins at the base of the tongue may be regularly or 
irregularly dilated. In the former condition they will ap- 
pear as bluish, sinuous cords, while in the latter there will 
be a nodular appearance. These may rupture, and occa- 
sionally a severe hemorrhage will result. In females it may 
be especially marked at the menstrual period, during preg- 
nancy or the menopause. Alcoholism may also be a cause. 
In males there appears to be a tendency for this hemor- 
rhagic condition during the cycle which corresponds in a 
measure with the menstrual function in the female. This 
is as yet an undetermined factor in the male, but according 
to Havelock Ellis it undoubtedly is a factor, not only in this 
but also in rhinitic and pharyngeal diseases. 

Etiology. — As a rule is dependent upon impeded venous 
circulation, the primary cause of which may be intestinal, 
cardiac, hepatic, or renal lesions. 

Symptoms. — Generally subjective. Usually a sensation 
of a moving substance in the throat. In some cases there 
is the sensation of a soft foreign body at the base of the 
tongue. 

Treatment. — This should be directed to the primary 



376 Nose, Throat and Ear. 

cause. We know of two remedies which have a direct influ- 
ence upon varicosed conditions, collinsonia and hamamelis, 
and excepting in aggravated cases either of them, combined 
or alternated with the remedies directed to the primary 
cause, will prove effective. When persistent hemorrhage 
occurs, either the hamamelis or carbo-veg. should be given. 
Occasionally the galvano-cautery may be required. 

Laryngeal Tonsil. 

Located within the ventricle of the larynx small areas 
of adenoid tissue are found, which are properly lymph- 
follicles. It is only when inflammatory conditions of the 
larynx are present that they can be discerned as minute 
elevations. 

.. Treatment. — The same as directed for laryngeal inflam- 
mation. 



CHAPTER XIII. 
DISEASES OF THE PHARYNX. 

Malformations and Deform itiES ; Stenosis.— i. Dila- 
tation (Pharyngocele). Diverticulum. 

Acute Inflammatory Diseases. (i) Simple Acute 
Pharyngitis. (2) Infective Pharyngitis. (3) Membranous 
"Pharyngitis, (a) Croupous; Simple Membranous, (b) 
Diphtheritic. (4) Gangrenous Pharyngitis. (5) Trau- 
matic Pharyngitis. (6) Hemorrhagic Pharyngitis. (7) 
The Pharynx in Exanthemata and other Febrile Affections, 
(a) Scarlet Fever, (b) Small-pox. (c) Measles, (d) 
Erysipelas, (e) Intermittent Fever, (f) Gout, (g) Ty- 
phus Fever. (h) Typhoid Fever. (i) Influenza. (j) 
Varioloid, (k) Chicken-pox. (8) Ludwig's Angina. 

Chronic Inflammatory Diseases. (1) Simple Chronic 
Pharyngitis. (2) Subacute Pharyngitis. (3) Follicular 
Pharyngitis. (4) Hyperplastic Change in the Pharyngeal 
Structure. (5) Atrophic Pharyngitis. (6) Rheumatic 
Pharyngitis, (a) Acute, (b) Chronic. (7) Infectious 
Granulomata of the Pharynx and Nasopharynx, (a) Tu- 
berculosis. (1) Lupus. (b) Syphilis. (c) Glanders, 
(d) Actinomycosis. 

Abscess, Retropharyngeal. Urticaria. Herpes. Pha- 
ryngomycosis. 

Non-inflammatory Diseases. — (1) Pulsating arteries. 
(2) Anemia of the Pharynx. (3) Neuroses of the 
Pharynx, (a) Anesthesia, (b) Hyperesthesia, (c) Pares- 

377 



37& Nose, Throat and Ear. 

thesia. (d) Neuralgia, (e) Neuroses of Motion, (i) 
Spasms. (2) Paralysis. 

Foreign Bodies in the Pharynx. (Kyle.) 

Malformations and Deformities of the Pharynx. 

Stenosis is one of the most important malformations, 
and may be congenital, occur early in life, or be secondary 
to inflammatory or traumatic conditions. 
, Congenital atresia, complete or partial, seldom occurs. 

Secondary stenosis may result from cicatricial contrac- 
tion, either following specific inflammation or a traumatism. 
Syphilis is the most frequent of the former. Specific lesions 
of the pharyngeal tissues causing adhesions to the contig- 
uous structures, or contraction, is often found. This con- ( 
dition may exist either low in the nasopharyngeal or in the 
laryngopharyngeal space, and the peculiar stellate charac- 
teristic of a syphilitic scar is present. The treatment usu- 
ally is unsatisfactory, as time is an important factor, and 
the patient will not remain long enough under treatment. 
The stricture should be divided and dilated for a consider- 
able time, and active antisyphilitic measures adopted. 

Tubercular constrictions are practically unknown, as the 
tendency in these cases is to continue ulcerating. The in- 
fective diseases which are most liable to have adhesions and 
contractions as sequelae, are scarlet fever, diphtheria, small- 
pox, and erysipelas. 

Traumatic stenosis may occur at any period, and usually 
follows scalding by hot liquids or erosions of caustic liquids, 
taken accidentally or intentionally. Usually this traumatic 
lesion is rapidly fatal, not only on account of the extent of 
the lesion, but also because severe edema of the glottis is 
usually associated with the resulting inflammation. 

Treatment. — In these cases emollient remedies should be 
employed, usually those of an oily nature are preferable. 
A five per cent carbolized vaseline will often give relief. 



Malformations of thk Pharynx. 379 

Spasmodic contraction is usually the result of swallow- 
ing food before it is properly masticated. 

Extrinsic Stfnosis. — Disease of the cervical vertebrae 
is the most frequent cause. Any lesion of the spine which 
causes a constriction of the pharyngeal space may produce 
this condition. 

Retropharyngeal abscess may cause a diminution of the 
pharyngeal cavity. Increased size of the apices of the lat- 
eral lobes of the thyroid gland may, through pressure, pro- 
duce inflammation and cause choking sensations. 

When the cervical glands are affected in Hodgkin's 
disease, the pharyngeal space may be diminished. 

Diverticula, or Dilatations of thf Pharynx. — This 
may occur through arrested development in fetal" life, or 
result from imperfect growth or mechanical distention. 
Congenital pouches are usually associated with total atresia 
of the pharynx, or absence of the esophagus. The cause of 
this condition is not definitely known. 

Pouches or dilatations of the pharynx (pharyngocele) 
are oftenest found in old age, although they may be over- 
looked earlier in life. The most frequent cause is the in- 
gestion of improperly masticated food. Usually the first 
manifestation of a morbid state, is the inability to swallow, 
or pain on attempting to do so. Masses of undigested food 
may be ejected, without the effort to vomit, and may occur 
at any time after eating. Occasionally the pouch may be 
so large that the contained food will produce a visible dis- 
tention on that side of the neck, and the patient may be able 
to cause the food to enter the esophagus by making pressure 
against the distention. 

Treatment. — Usually unsatisfactory. When the pouch 
is large, causing a visible swelling of the neck, a properly 
adjusted pad may relieve the condition. The galvano- 
cautery, or freshening the edges of the pouch and suturing 
have been advised, but the results are usually unsatisfactory. 



380 Nose, Throat and Ear. 

Simple Acute Pharyngitis. 

Synonym. — Acute catarrhal pharyngitis. 

This corresponds to an acute catarrhal inflammation of 
mucous tissue -in general. , 

Etiology. — This may be the result of a simple "cold," 
exposure, or by extension from contiguous structures. A 
rhinitis or nasopharyngitis may be the direct cause. Dis- 
turbances of the alimentary canal may also cause it, through 
impaired vitality of the general system, producing a les- 
sened resistance of the pharyngeal structures. 

Influenza, systemic diseases, poor hygienic surroundings, 
sedentary habits, any of these may more or less be factors 
in causing an acute pharyngitis. Inflammatory affections 
of the lingual tonsil often cause symptoms simulating acute 
pharyngitis. Alcoholism, or the excessive use of tobacco, 
may predispose through their influence on the general sys- 
tem. It probably is oftenest found in youth and middle age. 
In children intestinal irritation is frequently the cause. Oc- 
cupation is a factor, as those who are exposed to irritating 
fumes, dust, hot dry air, or sudden changes of temperature, 
are more liable to acute pharyngitis than when the surround- 
ings are more favorable. 

Pathology. — This is the same as in an acute catarrhal 
inflammation of any mucous tissue. 

Symptoms. — The attack is usually sudden, and the sever- 
ity depends upon the rapidity of onset, The membrane 
varies in color from a bright pink to a deep red. The 
pharyngeal vessels are usually distinctly congested. There 
is always a distinct band extending along the pillars of the 
fauces and the edge of the soft palate, including the uvula. 
The width and intensity of color of this band will determine 
not only the severity of the attack, but also the stage. The 
broader and deeper the color, the more severe the inflamma- 
tory action. If in the early stages, the band is sharply de- 
fined, while later the outer edge of the band merges in color 



Simple Acute Pharyngitis. 381 

into that of the continuous tissue. Some edema of the edges 
of these structures may be present, giving a translucent ap- 
pearance. 

In the early stage the membrane is smooth and shining, 
becoming roughened in the second stage. In the first stage 
the throat is dry, with small masses of mucous scattered 
over the surface. 

The second stage is characterized by profuse secretion 
and exudate. At first this is watery, becoming tenacious 
and mucopurulent as the process progresses. When the 
exudate is fibrinous, it will coagulate on the mucous mem- 
brane. The constant effort to clear the throat increases the 
irritation. There is usually severe pain and irritation, which 
is augmented on swallowing. There is a sensation of full- 
ness or constriction of the throat, with a constant desire to 
swallow. The pain often extends to the ear, even without 
the presence of a nasopharyngitis, and is usually increased 
by the act of deglutition. 

The larynx may- be affected by extension of the inflam- 
mation through continuity of tissue. Whether or not the 
hearing is impaired will depend upon the involvement of 
the nasopharynx. The act of swallowing increases the pain, 
and the sense of taste is usually impaired. The desire to 
clear the throat will cause more or less constant hawking 
or coughing, and in those cases where there is laryngeal or 
bronchial irritation the cough will be more spasmodic. 
Quite often the sputum will be streaked with blood, as the 
result of rupture of some of the congested blood-vessels. 

The respiration is free, unless there is laryngeal or nasal 
complications. The voice is changed in character, and in 
laryngeal involvement may be lost. 

The systemic manifestations depend largely upon the 
severity of the case, as well as whether it is associated with 
an epidemic condition. There will be increased temperature, 
gastric disturbances, constipation, and scanty, high-colored 



382 Nose, Throat and Ear. 

urine. The tongue will be coated and the breath offensive. 
Headache and pain in the muscles of the neck are usually 
severe when epidemic conditions are present. 

Diagnosis. — This is not difficult, in the majority of cases. 
In children a hasty diagnosis should not be made, as the 
pharyngeal symptoms may precede some systemic disease. 

Prognosis. — Good. Under proper treatment an uncom- 
plicated case should recover in three to five days. 

Treatment. — This should consist of constitutional meas- 
ures, as local means are practically worthless, excepting to 
amuse the patient. During the early stages, aconite, dist. 
hamamelis, nux, belladonna, gelsemium, apis, apocynum, 
hydrastis, potassium bichromate, phytolacca, rhus tox., or 
cimicifuga, are usually indicated. 

When the pharyngeal lesion is the result of systemic 
disease, the latter should be treated, but the treatment given 
above will reach the majority of cases. In cases of hepatic 
engorgement, chionanthus gtt. jv. should be given. This 
drug will do better work if it is given in concentrated form, 
with directions to drop it in water when taken. If put into 
a watery menstruum, it appears to lose its medicinal prop- 
erties very rapidly. # 

The use of opiates is seldom required, and should be 
avoided if possible, as their action is to retard recovery. 

Infective Pharyngitis. 

Symptoms. — Ulcerative sore throat ; Hospital sore 
throat; Phlegmonous pharyngitis; Suppurative pharyn- 
gitis. 

This is an infective condition, in which there is super- 
ficial ulceration of the pharyngeal mucous membrane. 

Etiology. — Persons exposed to septic influences, when 
the vitality is lessened, are liable to infective pharyngitis. 
Physicians not infrequently have this disease during epi- 
demics of diphtheria or scarlet fever. In hospitals the at- 



Infective Pharyngitis. 383 

tendants are often affected. It is also a not infrequent con- 
dition among those working in dissecting rooms. The bac- 
teria usually found are the streptococci and staphylococci. 
The pseudobacillus of diphtheria may be present, but is not 
a factor. 

Pathology. — Ulceration of the pharyngeal mucous mem- 
brane may occur in nearly any inflammatory action of these 
tissues, but is usually the result of an infection. Liquefac- 
tion necrosis is characteristic, small ulcers often extending 
through the basement membrane, resulting. In some cases 
the process is not decidedly ulcerative, being desquamative, 
the basement membrane not being implicated. Sometimes 
the infection localizes under the mucous membrane, forming 
an abscess, or the superficial tissue may secrete pus through 
the infection, a granular appearance resulting, which causes 
the suppurative form. If there are small abscesses in the 
submucosa, a diffuse suppurative pharyngitis — peripharyn- 
geal, phlegmon — results. Excepting in diphtheritic infection, 
the different varieties differ only in degree. 

Symptoms. — The first symptom is sensitiveness of the 
throat, increased on swallowing. This is soon followed by 
dryness and a swollen and rigid sensation. Pain extending 
from the throat to the ears, and muscles of the neck and 
pharyngei muscles sore. The temperature is increased. 
Restlessness and depression is complained of. The secre- 
tions are scanty, the tongue coated with a heavy fur, and 
the breath offensive. There is often dull frontal headache 
and mental dullness. 

The ulcers are usually on the lateral walls of the phar- 
ynx, often behind the faucial pillars, when they are fre- 
quently overlooked. The tonsils and velum are often af- 
fected. The ulcer is generally small, and has a shaggy 
membrane covering it. This is the result of liquefaction — 
and coagulation — necrosis. After this substance has 
sloughed the ulcer will be clear. 



384 Nosk, Throat and Ear. 

Diagnosis. — The history, rapid development, and micro- 
scopic examination will determine the character of the 
lesion. 

Prognosis. — Usually favorable. Septicemia may occur. 

Treatment. — The nature of this disease requires placing 
the patient under good hygienic surroundings. The bowels 
should be freely evacuated, a saline cathartic being prefer- 
able. For the suppurative tendency, the use of lime, either 
lime water or calcium sulphide, every hour. For the septic 
condition, especially with dusky, leaden-colored ulcerations, 
baptisia. When the surfaces of the ulcers are dirty looking, 
the mucous membrane bluish or purplish in color, and an 
asthenic type of ulceration, echinacea. 

Besides these remedies, the drugs given under acute 
simple pharyngitis will usually be sufficient. 

Membranous Pharyngitis. 
Varieties. — Croupous ; Simple membranous ; Diphtheria. 

Croupous. 

Not infrequently there is seen an inflammatory condition 
which is of an infectious character, but is not diphtheritic. 
While the streptococcus pyogenes are found in abundance, 
giving rise to the term streptococcal infection, yet they are 
not the cause of the disease. Some writers describe this 
as erysipelas of the throat. Clinically it is difficult to dis- 
tinguish from diphtheria, but it runs its course more rapidly, 
and is not as severe. 

Among laboratory workers, or persons exposed to infec- 
tious conditions, the disease is most frequent. 

There is neither ulceration nor implication of the base- 
ment membrane, as there is in ulcerative pharyngitis. The 
mucous membrane is covered with a very coagulable albumi- 
noid substance, which forms a false membrane and is coin- 
cident with desquamation of the surface epithelium. Or. 



Gangrenous Pharyngitis. 385 

removal of the membrane no ulceration will be found, and 
should there be any bleeding it will be simply a capillary 
oozing. Whether this condition is contagious or infectious 
has not been determined, but until the diagnosis is positively 
made due care should be taken, as the earlier diphtheritic 
symptoms are almost identical. 

Diagnosis. — This is made from the clinical symptoms 
and also by microscopic examination. 

Treatment. — The surfaces should be kept as clean as 
possible, and for this purpose the salicylic acid wash will 
be found especially useful. A two per cent solution of 
potassium bichromate is also a remedy that is indicated in 
many cases. Swabbing of the tissues or any rough manip- 
ulation is to be avoided. Internally the treatment should be 
along the indicated line given under simple pharyngitis. 

Diphtheria. 
As this disease is fully described and the methods of 
treatment given in works on Theory and Practice, it will 
not be described. The only thing in these cases is to avoid 
the barbarous methods in vogue of swabbing the throat. 

Gangrenous Pharyngitis. 

Synonym. — Putrid sore throat. 

This infrequent affection is the result of an antecedent 
disease, infectious in character. It is generally associated 
with the infectious febrile diseases, or as a sequelae of 
trauma, either accidental or operative. It is caused by the 
localization of an infectious process in the submucosa. An 
infected embolus may lodge in the submucosa and be fol- 
lowed by abscess formation. As the nutrition of the base- 
ment membrane is obtained from the submucosa, if this sup- 
ply is interfered with by an infectious process, necrosis fol- 
lows. On the surface of the mucous membrane, over the 
25 



386 Nose, Throat and Ear. 

affected portion, there is an accumulation of inflammatory 
fibrinous material, the removal of which also removes a 
slough. Practically the condition is a localized superficial 
necrosis, affecting the basement membrane as well, thus re- 
sulting in a true ulcer. 

This gangrenous condition may be the result of local 
infection, liquefaction necrosis of the epithelium following, 
and the affection of the deeper tissues through the lymph 
channels. This forms a severe phlegmonous inflammation 
with sloughing of the infected area. 

Symptoms. — The onset is sudden, and the disease runs 
a rapid course. Usually there is a rapid increase of tem- 
perature, as a result of toxic poisoning. If actual necrosis 
results, there may be a sudden decrease of temperature to 
subnormal. Pain, as a rule, is severe and lancinating in 
character. The cervical and submaxillary glands are often 
enlarged. With the advent of necrosis, the breath becomes 
extremely fetid, the characteristic odor of gangrenous tis- 
sue. Prostration and mental depression are present as in 
other septic diseases. Sepsis results not only from the local 
area, but also through the alimentary tract, the result of the 
patient swallowing the infected material. 

Prognosis. — Unfavorable, it being often impossible to 
check the disease, and the patient dies from syncope. 

Treatment. — Internal medication is the only hope. Echi- 
nacea, baptisia, potassium chlorate, calcium sulphide. The 
eliminative functions should be kept active, and so-called 
stimulating remedies employed. Locally, a spray or wash 
of potassium permanganate or potassium chlorate may aid 
in relieving the odor. The surfaces may also be cleansed 
with some solution, so that a less quantity of the secretion 
is swallowed. 

Occupation Pharyngitis. 

Synonym. — Traumatic pharyngitis. 

This is an acute inflammation, the result of wounds, for- 



Occupation Pharyngitis. 387 

eign bodies, inhalation of irritative dusts or vapors, or of 
caustic substances. 

Etiology. — Young children or feeble-minded persons are 
most frequently the class in which this condition is observed, 
as they are more liable to drink corrosive solutions or boil- 
ing liquids. It is also frequently seen in adults whose voca- 
tion keeps them more or less constantly exposed to irritat- 
ing dust, as sweepers, miners, weavers, threshers, etc. 
Those who work in chemical laboratories are also often 
affected. The lodging of sharp foreign bodies of any kind 
in the pharyngeal tissue is often a cause. In the latter cases 
the inflammation spreads from the point of irritation to the 
surrounding tissue. If the submucous connective tissue is 
injured, suppuration and abscess formation is liable to 
result. 

When the inflammation is caused by vapors, chemical 
fumes, dust, or fluids, the tissues are more regularly af- 
fected, no focus of inflammation being found. The mem- 
brane of adjacent structures is also involved. If the excit- 
ing cause is a caustic solution, a scald or burn, edema of 
the glottis, as well as of the pharyngeal tissue, is liable 
quickly to follow the injury. The inflammatory action is 
very severe and rapid in its progress. 

Treatment. — If due to a foreign body', this should be re- 
moved as soon as possible. Often the offending substance 
has been removed, and there is simply the infected trau- 
matism when the patient is seen. If there is edema, numer- 
ous punctures should be made in the tissue. In burns, 
caustics, etc., the parts should be thoroughly covered with a 
five per cent carbolized vaseline, which will allay the pain. 
Any oily substance may be used, however. In some cases 
the edema is so severe and sudden as to require intubation 
or tracheotomy, and in some cases it may extend so low in 
the trachea that neither method will do any good. It is 
impossible to state here the antidotes for the various es- 



388 Nosk, Throat and Bar. 

charotics. Such local means should be employed as will 
relieve the pronounced pain. 

Hemorrhagic Pharyngitis. 

Etiology. — In hemorrhagic pharyngitis there are single 
or multiple small areas of extravasated blood, the result of 
ruptured blood-vessels, the inflammatory action being sec- 
ondary to the hemorrhage. It is often found after the erup- 
tive fevers, or any condition causing relaxation of the walls 
of the vessels and perivascular tissue. The hemorrhagic 
nidus appears like small, dull red, slightly edematous spots. 
If seen within twenty-four hours, inflammatory action may 
be absent, but after this period there is usually an active 
inflammation. 

The rule is for the areas to be located on either side of 
the median line, but any portion of the pharyngeal surface 
may be affected. Usually the condition shows as multiple 
spots, but there may be but one. If the hemorrhage is 
slight, the appearance will be similar to the petechias of 
eruptive fevers. 

In specific processes, as syphilis or tuberculosis, hemor- 
rhagic areas may be found in the mucous membrane of the 
uvula and soft palate. 

Symptoms. — These are about the same as in acute phar- 
yngitis, but are generally of longer duration. Blood stained 
or streaked mucus may at times be expectorated. Pain is 
not severe, but as a rule is localized. In some cases necrotic 
changes occur in the hemorrhagic spot, ulceration follow- 
ing, which is termed hemorrhagic ulceration of the pharynx. 

Treatment. — The inhalation of steam may afford relief, 
but the main treatment must be directed to the systemic 
lesion. The bowels should be kept in good condition. The 
treatment given under acute pharyngitis should be followed. 



The Pharynx in Febrile Diseases. 389 

The Pharynx in the Exanthemata and Other Febrile 

Diseases. 

Chicken Pox. — In severe cases, when the eruption is 
considerable, there are often pharyngeal complications, al- 
though the hard and soft palate are most affected. Flaccid 
vesicles which have a surrounding area of hyperemia are 
usually found. The epithelial surface of the vesicles rap- 
idly desquamate, leaving excoriations. The lymphatics of 
the neck may be swollen and tender, and there is usually 
considerable pain in the throat. 

Erysipelas. — This may be primary or secondary. The 
tissues swollen, livid, red, and shining, with the formation 
of vesicles varying in size from a pinhead to one-half inch 
in diameter, leaving a gangrenous area, comprise the phar- 
yngeal phenomena. In epidemic erysipelatous fever, usu- 
ally called "black tongue," not only the pharynx, but also 
the larynx, may become involved. If the pharyngeal lesion 
is secondary, it may be by extension from the cuticle 
through the mouth, nose, or even the ears, or by metastasis 
from the integument to the mucous tissues. The systemic 
disturbances are most persistent. 

Symptoms. — Difficulty in swallowing and a sharp pain 
in the throat are usually the first symptoms. After efflores- 
cence occurs the fever often decreases, again increasing 
with another crop of vesicles. The vesicles may contain 
serum, pus, or blood. Gangrenous spots may form. The 
disease may extend to the accessory sinuses, tonsils, and 
middle ear. Erysipelas of the pharynx may be a compli- 
cation of smallpox or almost any febrile disease. 

Prognosis. — Guarded, as by extension it may terminate 
fatally. 

Gout. — Pharyngeal and laryngeal inflammatory phe- 
nomena, the result of the systemic disease, may occur. The 
throat symptoms may precede or follow the actual attack. 
There are no distinctive appearances, the diagnosis depend- 



390 Nosk, Throat and Ear. 

ing largely upon the previous history. The pain usually is 
sharp and more or less constant. 

Influenza (La Grippe). — An acute catarrhal condition 
of the pharyngeal tissue is usually present. The nasal and 
nasopharyngeal tissues are almost always affected. There 
is a decided tendency to a chronic type. Ulcerative proc- 
esses may occur, and a croupous exudate on the tonsils and 
posterior pharyngeal wall has been seen. The pain may be 
severe. 

Intermittent Fever. — The entire respiratory tract may 
have, as a result of changes in the blood, an irritative in- 
flammation. There may be coryza, and paralysis of the 
muscles of deglutition has been observed. In the pharynx 
a burning pain is sometimes complained of. A subacute 
pharyngitis or enlargement of the tonsils may occur. 

Measles. — The catarrhal inflammation of measles is 
most marked on the laryngeal and bronchial tissues, but 
there is a characteristic appearance of the mucous mem- 
brane of the fauces, palate, uvula, and pharynx. There may 
be diffuse redness, or a blotchy or punctate rash, which may 
appear with, or precede, the cutaneous manifestation. The 
middle ear may be involved through extension of the in- 
flammatory process through the Eustachian tube. 

Scarlet Fever. — In this disease throat symptoms are 
probably always present, the severity depending on the 
variety of the disease. 

According to Dr. R. E. Thomas, the throat lesions are 
of three types. In the simple form there is redness of the 
fauces, tonsils, tonsillar follicles, velum, and pharynx, and 
a sensation of obstruction in the throat. In the anginosa 
form all the tissues are a vivid red, and there is consider- 
able swelling of the structures, the sensation of an obstruct- 
ive condition of the throat being marked. There is con- 
siderable induration and often follicular tonsillitis. Sore- 
ness is present from the onset of the disease, and deglutition 
is painful and difficult. The secretion from the mucous 



TFhe Pharynx in Febrile Diseases. 391 

follicles and salivary glands is excessively viscid and te- 
nacious. Occasionally ulceration may begin on the fifth or 
sixth day, the secretion being difficult of removal and very 
offensive. The ulcers may become phagedenic in character, 
the disease then being rapidly fatal. The cervical glands 
may be enlarged, and if neglected inflame and suppurate. 

In scarlatina maligna the third form is found, which is 
sometimes called membranous angina. The throat at first 
is dry and tumid, soon showing a dirty moist exudate ; the 
deeper tissues become infiltrated, and the inflammation is 
extreme. The submaxillary glands are swollen as well as 
the cervical. Foul phagedenic ulcers are found in the phar- 
ynx. Suppuration of the cervical glands ensues, and a 
disgusting pultaceous abscess results. 

The latter form, when it occurs early, or even later than 
the fifth or sixth day, is ascribed to the Klebs-Loffler bacil- 
lus, a true diphtheritic type, or to streptococci, or different 
forms of micrococci. The general appearance is suggestive 
of diphtheria. 

Any of these types may by extension involve the Eu- 
stachian tubes and middle ear, causing a suppurative" otitis 
media. Deafness from inner ear complications is not infre- 
quent, although in what manner the infection causes laby- 
rinthine disease is unknown. 

Small-pox. — Pharyngeal manifestations may be ob- 
served during either the stage of infection, or occasionally 
the incubation period. It may be a dusky appearance of 
the mucous membrane, or a catarrhal inflammation with 
swelling of contiguous tissues. Occasionally there is lym- 
phatic involvement. Ecchymoses and membranous exuda- 
tion in the pharynx may appear before the cutaneous erup- 
tion in hemorrhagic small-pox. Usually the eruption in the 
throat appears after the cutaneous eruption. If a pseudo- 
membrane forms in the throat, there will be intense pain 
and difficult deglutition. 



392 Nose, Throat and Ear. 

Complications and sequelae: Infectious inflammation of 
the parotid and other glandular structures, abscess of the 
larynx, and often purulent otitis media. 

Typhoid Fever. — As is to be expected, pharyngeal and 
laryngeal affections are comparatively frequent in this dis- 
ease, especially laryngeal. It may be a catarrhal, croupous, 
follicular, ulcerative, or diphtheritic and aphthous pharyn- 
geal inflammation. In the early stages there is often dry- 
ness of the throat, making the effort to swallow more or less 
difficult. Later the difficulty in swallowing may be simply 
a nervous condition, especially in children. The pharyn- 
geal, faucial, lingual, and tonsillar follicles may be affected 
coincidentally with the intestinal glandular involvement. 
Infrequently there may be so much infection that the terms 
tonsillo-typhoid or pharyngo-typhoid may be used. 

Bone and cartilage necrosis or abscess formation, as a 
result of the lowered vitality, is most to be expected, and the 
most serious lesions are oftener laryngeal than pharyngeal. 

Typhus Fever. — The pharyngeal mucous membrane 
and buccal mucosa are usually involved. The color is a 
dusky red, injected, and the mucous follicles enlarged, con- 
taining puriform material, or puriform areas may occur in 
the areolar tissue of the posterior pharyngeal wall. A vis- 
cid mucus or flakes of pseudo-membranous exudate may 
cover the mucous membrane. There may be difficulty in 
swallowing. Unless infection occurs, suppuration or ulcer- 
ation is infrequent. 

Varioloid. — Usually not much involvement of the phar- 
ynx. In some cases, however, there may be hoarseness, 
and difficulty in swallowing. 

Ludwig's Angina. 

Synonyms. — Angina Ludovici ; Cellulitis of the neck. 
This is really an acute cellulitis of the neck, and gener- 
ally is secondary to septic fevers, as diphtheria and scarlet 



Simple Chronic Pharyngitis. 393 

fever, but may result from traumatisms. It is supposed to 
be of bacterial origin. The pharyngeal symptoms, which 
are severe and come on rapidly, are soon followed by infec- 
tion of the parotid or submaxillary glands, and suppuration 
rapidly supervenes. 

Prompt remedial measures may give relief. If not, 
surgical means must be employed. This must not be de- 
layed, on account of the danger of constitutional infection. 

Simple Chronic Pharyngitis. 

Synonyms. — Clergymen's sore throat; voice users sore 
throat ; exudative pharyngitis. 

This form of pharyngitis is a chronic inflammatory con- 
dition of the mucous membrane, permanent changes result- 
ing in the glands or submucosa. 

Etiology. — The disease may be caused by a long con- 
tinued acute or subacute pharyngitis. The prolonged use 
of the voice by public speakers, especially those who have 
not acquired the proper method of controlling the muscles, 
will produce as a reaction muscular contraction of the 
larynx and pharynx, with anemia of the tissues. After re- 
laxation of the muscular tissues occurs, dilatation of the 
vessels results, and there is stasis. Frequent repetitions of 
this condition will produce changes in the perivascular tis- 
sue nearly identical with those of chronic inflammation. 
The morbid change is very similar to that of cyanotic con- 
gestion. The pathological changes are always the same in 
this disease, although the causes and symptoms may differ. 

Systemic diseases in which modification of the nutrition 
occurs as a result of venous stasis or cyanotic congestion, 
due to liver, lung, kidney, or cardiac lesions, may be an ex- 
citing cause. Some nervous states, especially peripheral, 
may have a causative influence in these cases. Digestive 
wrongs, through lowering of the general resisting power, 
will often prove an exciting cause. The abuse of stimulants 



394 Nose, Throat and Bar. 

or narcotics will cause a chronic pharyngitis. Sexual ex- 
cesses are also credited as favoring the condition. The ex- 
cessive use of tobacco will cause local irritation, which is 
acutally only a symptom of systemic conditions, the result 
of the absorption of the tobacco alkaloids. 

Gouty or rheumatic persons, those suffering from auto- 
intoxication, or from any impairment of the excretory or 
secretory organs, are especially liable to this disease. Mal- 
formations of the pharynx will also have a causative influ- 
ence. The different types of rhinitis will also be factors, 
either through extension of the inflammatory state, or by 
the passing of the nasal discharge over the pharyngeal tis- 
sue. The latter condition may be the cause, as a result of 
the irritation produced, or through the efforts to clear the 
throat. Mouth breathers are often affected, even when not 
speakers. 

Pathology.— z The pathological changes found in the tis- 
sues in chronic pharyngitis vary, and many of the so-called 
diseases .are simply definite stages of the inflammatory ac- 
tion. In simple chronic pharyngitis the inflammatory 
change in the submucosa is slow. There may be only a 
slight exudate from the blood-vessels on account of but little 
irritation ; a few leukocytes will be found in the exudate, 
and proliferation slowly occurs in the connective tissue 
spaces. This, in connection with slow proliferation of the 
fixed connective tissue cells, gradually causes a permanent 
thickening of the mucosa. This increase of the connective 
tissue elements causes more or less irritation of the gland- 
ular elements, and there is an increase of secretion. As 
organization of this inflammatory material occurs, the 
glandular elements of the submucosa are subjected to pres- 
sure, through the increased amount of organized material. 

Eventually this organized inflammatory material will 
commence contracting, and there is necessarily a change in 
the condition, the inflammatory stage having subsided, and 



Simple Chronic Pharyngitis. 395 

pressure atrophy resulting. These pathologieal changes 
vary in rapidity and according to the cause, still the change 
is practically the same in all cases of chronic pharyngitis. 

A condition is found in which there is an actual increase 
in connective tissue elements, which is more like a hyper- 
plasia. This is not a true hypertrophy, as there is a decrease 
in function of the membrane. When this is the case, atrophy 
does not take place ; the mucous membranes do not become 
dry, and accumulations of changed secretion on the surface 
are not found. 

Symptoms. — The mucous membrane is irregularly hy- 
peremic or congested. The variation in color is marked, 
the border of the pharyngeal structure being bright colored, 
and the balance of the tissue showing more the color of 
congestion. The palatine folds and the lower and anterior 
margin of the velum are light red. The posterior pharyn- 
geal wall often shows congested capillaries and small veins ; 
the surface is irregular, but not so marked as in true follic- 
ular pharyngitis. At the base of the tongue varicosed ves- 
sels are often found; this is more prominent after contrac- 
tion has occurred. 

The depressions in the pharyngeal tissue will be filled 
with a tenacious secretion, which, unless carefully noticed, 
will be taken for membranous inflammation. If the disease 
is the result of any of the forms of pneumoconiosis, the se- 
cretion will be colored according to the material which 
causes the inflammatory action. 

The secretions are changed as a result of the morbid 
processes ; they are more tenacious as the changes become 
more marked, and there is a tendency to crust formation. 
The character of the voice is changed, hoarseness and lack 
of control being most marked ; the voice is weak, lacking 
carrying power, and the muscles of the throat ache when a 
prolonged effort to use the voice is made. This sensation is 
wholly or partly relieved by making a slight pressure on 



396 Nose, Throat and Ear. 

the neck with the fingers. In singing, the range is lessened, 
and there is not full control of the tone and pitch. Unless 
some complications exist, nasal respiration is fairly free. 

An irritating, hacking cough is present, with a constant 
desire to clear the throat. Occasionally there are streaks of 
blood in the expectoration, the result of rupture of some of 
the congested blood-vessels. There is a continual desire 
to swallow ; this results from the enlarged lingual tonsil 
and accumulation of secretion in the pharynx. There is 
often a sensation of a foreign body in the throat, similar 
to the condition of globus hystericus. Pain on swallowing 
is variable, depending upon the amount of inflammation 
and the, stage of the process. Usually there is not much 
pain, unless warm fluids or highly seasoned foods are taken. 

The sense of taste is not much impaired, unless the an- 
terior pharynx and nasal cavities are affected, when both the 
senses of taste and smell will be markedly lessened. If the 
Eustachian tubes are involved the hearing will be impaired. 

The secretions are always increased after eating, caus- 
ing paroxysms of coughing and hacking, which may be 
severe enough to result in vomiting. The inhalation of dust 
or irritating vapors, or sudden changes of temperature, as 
going from a warm room into a cold, will also cause a 
coughing paroxysm. Gastric wrongs are usually present, 
jand may be either primary or secondary. Laryngitis is 
often associated with the pharyngeal lesion. 

Diagnosis. — Easily made. 

Prognosis. — This will depend upon the causative factor. 
If this can be removed, the prognosis is good ; otherwise not. 
m Treatment. — The general health must be considered in 
this disease." The alimentary tract must be kept in an active 
condition, and the remedies employed for this purpose 
should be carefully selected. 

Local. — Often it will be necessary to use the atomizer 
for cleansing the mucous surfaces. Either the alkaline 



Follicular Pharyngitis. 397 

wash or the salicylic acid solution will be all that is neces- 
sary. 

Internal. — Besides what has been said regarding the ali- 
mentary tract, the remedies most frequently required are 
Phytolacca, iris, potassium bichromate, potassium iodide, 
bryonia, hydrastis, jaborandi, liquor potassii arsenitis, nux 
vomica, , podophyllum, ignatia, penthorum sedoides, hama- 
melis, collinsonia, or arsenious acid. % 

Should there be any malformation of the bony frame- 
work of the pharynx, a complete cure is impossible. 

Subacute Pharyngitis. 

This is really a late stage of an acute condition, either 
where the treatment has been unavailing or neglected. 

Symptoms. — The same as in the later stages of an acute 
attack, or the early stage of the chronic. It is an inter- 
mediate form. 

Treatment. — The same as in simple chronic pharyngitis. 

Follicular Pharyngitis. 

Synonyms. — Clergymen's sore throat ; dysphonia cleri- 
corum ; folliculous pharyngitis ; granular pharyngitis. 

In this disease the glands of the mucous membrane are 
especially affected. The secretion is changed in character, 
and in the advanced stages of the disease is very scanty, 
tenacious, and irritative. Irritation of the pharynx, often 
a sharp, hacking cough, and always a change in the voice, 
which varies from a slight hoarseness to complete aphonia. 
The appearance of the pharyngeal tissue is characteristic ; 
there is a varying amount of congestion, and numerous ele- 
vations of a reddish or yellowish color. These vary in size 
from a pinhead to a split pea, and may be discrete or coa- 
lesce. This uneven condition is caused by the inflamed and 
distended glands. When the secretion has been exuded, 



398 Nose, Throat and Ear. 

whitish or yellowish flakes of thick, whitish, or yellowish 
material will be found adhering to the elevations. 

Etiology. — Predisposing Causes. — Any condition which 
may cause a chronic inflammation of the respiratory mucous 
membrane may be a factor. The disease is seen more fre- 
quently in the young and middle-aged than in old age, and 
in men more than in women. Any diathesis or condition 
which lowers the resisting powers of the individual may 
have a predisposing influence. Climatic conditions are im- 
portant, as those subjected to a smoke-laden atmosphere 
will be more susceptible than those living in a clear atmos- 
phere. Whether the use of tobacco is a prophylactic or not 
is a question, but it certainly is not a remedial agent in this 
disease. 

Occupation is an undoubted predisposing factor, as those 
who use the voice considerably are more liable to the disease ; 
clergymen, auctioneers, lawyers, etc., are especialy liable to 
follicular pharyngitis. Actors and singers who have had 
proper vocal instructions are not often afflicted, but other- 
wise the disease is not infrequent. 

Follicular pharyngitis is really only a type of simple 
chronic pharyngitis, and besides the causes already given, 
it may follow frequent attacks of acute pharyngitis, or a 
neglected, severe, prolonged attack. 

Exciting Causes. — Improper use of the voice in any 
way, especially in the effort of loud or high-keyed notes. 
Faulty vocalization is probably one of the most frequent 
causes. This defect, when associated with impure air, either 
as a result of suspended material or lack of the proper 
amount of oxygen, unquestionably has an influence in caus- 
ing the disease. It is supposed that the ingestion of pungent 
condiments, through their influence on the glands, may also 
be an exciting cause. Many cases, however, are seen where 
no cause can be ascribed, and some, at least, are those hav- 
ing a marked tendency to glandular involvement. 



Follicular Pharyngitis. 399 

Pathology. — As regards the mucous membrane, the 
pathology is similar to that of a simple chronic catarrhal 
inflammation. The glandular structures, however, are af- 
fected particularly. Through overstimulation the function 
of the glands is exhausted, and the glands and surrounding 
tissue become inflamed. This practically results in encysted 
foreign bodies in the membrane, which are a source of con- 
stant annoyance. Inspection will reveal the morbid mem- 
brane studded with more or less reddish or yellowish ele- 
vations. The swelling may be partly due to inflammation 
of the tissue surrounding the glands, and partly to disten- 




FiG. 88. Follicular Pharyngitis. 

tion of the glands themselves through obstruction of their 
orifices. If rupture of the glands has occurred, there will 
be found a thick, pasty, cheesy, foul, light-colored material 
covering the site of the glands. This is termed the exudat- 
ive form. The microscopic appearances in the periglandular 
tissue are the same as present in ordinary inflammation. 
The openings of the glands are closed by inflammatory 
swelling, impacted cell masses, or inspissated secretion. The 
lumen of the glands or their ducts are enlarged, the lining 
epithelium swollen, and the cells show fatty degeneration. 
Calcareous deposits are sometimes present in the retained 
glandular secretion. Adhesion of the pillars of the fauces 
to the tonsils is a frequent complication. 



400 Nosk, Throat and Ear. 

Symptoms. — Usually there are repeated attacks of acute 
pharyngitis or a chronic inflammatory condition. The dis- 
ease is usually insidious. A not infrequent premonitory 
symptom is the excessive secretion of mucus or mucoid 
fluid on attempting to use the voice, the mouth being filled 
with the secretion. This action of the glands soon disap- 
pears, and the glandular involvement becomes apparent. 
The glands become inflamed, and the secretion is diminished 
in quantity. A dry or parched feeling is complained of, 
and there is a sensation of irritation in the throat, particu- 
larly after trying to use the voice. This is usually transient 
at first, but becomes more severe and of longer duration 
with each recurrence. 

The discomfort in the throat finally becomes permanent. 
The voice becomes hoarse, muffled, or even only a whisper, 
and sometimes even complete aphonia occurs, depending 
upon the severity of the disease and the effort made to use 
the voice. The pharyngeal tissues become "tired," and* occa- 
sionally painful in trying to talk, even in ordinary conver- 
sation. If there is much soreness of the tissue, speech may 
be hesitating and slow. The pain is usually of a burning, 
pricking, or stinging character. It may be a dull aching or 
bruised sensation, and deglutition often increases any of the 
symptoms. 

The secretion is not unlike that of a simple chronic 
pharyngitis. Cough is usually a troublesome symptom, and' 
is generally sharp and metallic, and may be constant or in 
paroxysms. This causes increased soreness of the pharyn- 
geal tissues. The uvula is often relaxed and increases the 
discomfort of the patient, as well as increases the cough. 
Through extension of the disease, the olfactory and auditory 
senses may be impaired. Disturbances of the alimentary 
canal are not infrequent, and this complication aids in the 
general depression sometimes found. 

Inspection reveals the characteristic appearance of the 



Hyperplastic Change. 401 

pharyngeal tissues, the elevations of a reddish or yellowish 
color and varying in size. These may be few or numerous, 
discrete or coalescing. A very frequent condition associ- 
ated with this disease is a band-like thickening behind the 
posterior pillars of the fauces, or even adherent to the pil- 
lars, interfering with the action of these muscles. This con- 
stitutes the condition called pharyngitis hyper trophic a later- 
alis. Depending upon the stage of the disease will be found 
irregular masses of cheesy material covering the follicles. 
Between the follicles will be dilated blood-vessels. More or 
less congestion of the entire pharyngeal membrane is usu- 
ally present. In advanced cases the tissues may all present 
a relaxed appearance, the uvula and velum often being 
flabby looking, and even the base of the tongue expression- 
less. 

Diagnosis. — Usually easy. 

Prognosis. — Good, in the majority of cases, provided 
the tissues are not overworked, and the patient will persist 
in the treatment. 

Treatment. — The general health should be considered, 
and, when possible, complete rest of the throat be given. 
The treatment given under simple chronic pharyngitis will 
usually suffice. In cases of long standing, where the glands 
and surrounding tissues have become permanently affected, 
the careful use of the galvano-cautery may be an important 
aid. It is important to remember that too much operative 
interference may result in a w r orse condition than the orig- 
inal disease. 

Hyperplastic Change in the Pharyngeal Structure. 
The mucous membrane and supporting tissue of the lat- 
eral pharyngeal walls may present a thickened condition. 
Contraction seldom occurs, as it is really a hyperplasia. It 
is usually termed pharyngitis hypertrophica lateralis, as the 
posterior surface is infrequently affected. It seems to be 
26 



402 Nose, Throat and Ear. 

an extension or association of chronic inflammatory action 
from contiguous tissue. It is practically found only with a 
chronic inflammatory nasopharyngitis. 

Atrophic Pharyngitis. 

Synonyms. — Dry pharyngitis ; pharyngitis sicca. 

This condition is the result of inflammatory processes, 
the changes being more or less permanent. 

Etiology. — The causes which lead to an atrophic pharyn- 
gitis are varied, but the morbid change which is produced 
is practically the same in all cases. Any exciting cause, 
as local irritants, may produce a chronic inflammation. 
Under this may be classed occupation irritation, where dust 
or irritating vapors are constantly inhaled. The pharynx 
becomes implicated through extension of inflammatory ac- 
tion from contiguous structures, causing first a thickening 
of the submucosa, followed by contraction. 

The contraction of inflammatory organized tissue affects 
the glands of the mucous membrane, changing the secre- 
tion, or even destroying the glands. The secretion which 
is present is so changed that it is a source of irritation. 

Systemic disturbances interfering with the circulatory 
system, especially where venous stasis results, may be a 
cause of atrophic degeneration. In these cases the general 
appearance of the membrane varies somewhat from that 
resulting from inflammatory atrophy, but the results are 
practically the same. 

Some nerve lesion, the cause* of which is difficult to 
trace, may also cause atrophy with similar results to those 
found following inflammatory processes. 

A dry pharyngitis, not atrophic, is often seen, which is 
the result of some systemic condition, changing the general 
nutrition and causing solidification of the glandular secre- 
tion. In this form of pharyngitis the secretion from the 
pharyngeal glands adheres to the mucous surface, and gives 



Atrophic Pharyngitis. 403 

a glazed or vanished appearance to the mucous membrane. 
These cases are not truly atrophic, but the result of per- 
verted secretion. It is found in diabetes mellitus, as well 
as in some forms of stomach and intestinal wrongs. 

The claim is made by some that atrophic pharyngitis is 
the result of atrophic rhinitis, but it is more likely that both 
are caused by the same factor. In some cases extension 
through continuity of tissue may occur, but they are prob- 
ably the exception. Impeded nasal respiration is undoubt- 
ed!" an important causative, factor in producing some types 




Fig. 89. Atrophic Pharyngitis. The thinning of the 
tissues shows fairly well. 

of dry pharyngitis, as mouth breathers, as a rule, are afflicted 
with this condition, atrophic changes eventually resulting. 
Pathology. — In the simple dry form, where the secre- 
tion simply dries and hardens on the pharyngeal surface, 
morbid changes in the membrane are very slight. The 
changed secretion may, through constant irritation, cause 
a chronic inflammation, which will eventally lead to con- 
traction of the inflammatory tissue, producing a true 
atrophic process. This necessarily produces changes in the 
vascular supply, and through pressure, changes or destroys 
the secreting action of the mucous glands. 



404 Nose, Throat and Ear. 

The morbid changes resulting from vascular wrongs, 
as often found in heart, lung, liver, kidney, or alimentary 
diseases, are due to lack of nutrition, as well as pressure 
on the perivascular structure by the overdilation of the 
blood-vessels, the glands also being affected. If this pres- 
sure continues for some time, pressure atrophy may follow, 
although occasionally slight inflammatory changes may have 
occurred early. The result is permanent, as in the true in- 
flammatory type. 

Symptoms. — The most pronounced symptoms are the 
burning, itching sensation and annoying dryness. As a re- 
sult of this dryness it is difficult to swallow solids without 
first moistening the mucous surfaces. A sensation of stiff- 
ness and rigidity of the throat is present. In some cases the 
secretions are so dry and firm that a grating sound can be 
heard when a probe or the end of a tongue depressor is 
passed over it. 

The character of the secretion varies according to the 
degree of change and its cause. In the simple form, where 
the submucous tissue is little affected, the membrane is thin, 
translucent, and smooth. As the pathologic changes in- 
crease in the submucosa and glands, the secretion becomes 
thicker, is irregularly massed, and is of a brown or green 
color. There is the sensation of a foreign body in the throat, 
which aids in increasing the hacking cough. 

The nasal cavities often, and the nasopharynx nearly al- 
ways, present a similar condition, and the Eustachian tubes 
are usually affected. 

In the early stage of atrophy, or in the simple dry type, 
the removal of the secretion will leave the mucous mem- 
brane reddened and extremely sensitive. Later, when there 
is crust formation, their removal will leave the surface with 
irregularly colored patches, some having an inflamed ap- 
pearance, and some being pale and colorless. The mem- 
brane appears thinner than usual, excepting in those cases 



Acute Rheumatic Pharyngitis. 405 

of atrophy due to venous stasis and pressure atrophy. In 
this class the surface is more nodular, the blood-vessels 
appear to be more on the surface, and, excepting in the lat- 
ter stages, there is not the tendency for the secretion to form 
in masses. The breath is usually offensive. 

Diagnosis. — Easy, as a simple inspection of the pharynx 
will reveal the condition. 

Prognosis. — Favorable in all forms in the early stages- 
Unfavorable after permanent atrophic changes have oc- 
cured. 

Treatment. — After the contraction of the mucosa has 
advanced to such an extent as to destroy the glandular ele- 
ments of the tissues, only palliative measures will be of use. 
Prior to this, however, a partial or complete cure can be 
obtained. The condition of the nasal and postnasal tissues 
must also be considered in these cases. 

Local Treatment. — This has but little effect, only as it 
removes a source of irritation by the removal of the tena- 
cious or dried secretions. This secretion can be removed 
in many cases by the use of an alkaline wash. Sometimes 
the use of pledgets of cotton on a curved probe will be nec- 
essary. The salicylic acid wash has been found to be one 
of the best local applications in these cases, as it has the 
property of stimulating glandular activity. Irritating meas- 
ures are to be avoided. 

The same general line of treatment should be followed 
as in atrophic nasopharyngitis. 

Acute Rheumatic Pharyngitis. 

Synonyms. — Rheumatic sore throat ; Rheumatic angina ; 
Gouty sore throat. 

This is an acute inflammation resulting from some con- 
stitutional irritant. The uric acid diathesis is at present 
credited as the cause. 



406 Nose, Throat and Ear. 

Etiology. — The uric acid diathesis may manifest itself 
in different ways. The secreting or glandular tissues may 
be unduly irritated through an excessive amount of work 
being required of them. This applies to the pharyngeal tis- 
sues, as well as the renal. The membranes of the nasal, 
laryngeal, or alimentary tract may be the point of local 
manifestation. 

Pathology. — The morbid changes in an acute attack are 
identical with those of a catarrhal inflammation. It must 
be remembered that in this condition we have merely a local 
maifestation of a systemic disorder, the result being an 
overworking of the glandular structures of the mucous 
membrane. Ulceration of the pharyngeal tissues occurs, 
but usually is confined to small areas. 

Symptoms. — The attack is usually sudden, the first symp- 
tom being a sensation of fullness in the throat, and pain, 
increased on swallowing. The desire to swallow becomes 
constant and difficult, the throat feeling rigid and stiff. 
There may be a sensation of heat ? dryness, and irritation, 
or a suddenly increased flow of mucus. There is always 
a tendency to clear the throat, which if continued becomes 
a source of irritation. The act of swallowing appears to 
reveal a new area of soreness, and the head assumes a dif- 
ferent position during each deglutition, which is character- 
istic of rheumatic pharyngitis. The attack may continue a 
few hours or several days. Acute exacerbations are fre- 
quent. General rheumatic symptoms may be present. The 
contiguous mucous membranes may be affected, but not to 
the same extent. The symptoms often pass away as quickly 
as they came. The pain is superficial. Slight febrile symp- 
toms may be present. 

Diagnosis. — An examination of the urine makes the 
diagnosis positive, but the sudden onset and a rheumatic 
tendency will suffice. 



Chronic Rheumatic Pharyngitis. 407 

Prognosis. — Favorable. 

Treatment. — The general health of the patient must be 
considered. Hygienic measures must be instituted, and the 
eliminative functions improved. The employment of sodium 
salicylate, bryonia, phytolacca, cimicifuga, rhus tox., rham- 
nus Californica, etc., according to indications, will give re- 
lief. The kidneys should be required to perform their func- 
tions, and potassium acetate, apis, apocynum, or similar 
remedies employed. 

Chronic Rheumatic Pharyngitis. 

Synonym. — Gouty sore throat. 

A chronic inflammatory condition, permanent changes 
resulting from the continued irritation of the uric acid dia- 
thesis. 

Etiology. — Simply the result of, or the continuation of, 
repeated acute attacks. 

Pathology. — A permanent thickening of the connective- 
tissue elements of the submucosa. 

Symptoms. — In the acute attacks the symptoms are the 
same as of a rheumatic pharyngitis. There is always pres- 
ent 'a sensitive condition of the tissues, a hacking cough, 
and a continuous effort to clear the throat, as a result of the 
accumulated mucus, or irritation resulting from the chronic 
condition. Sudden changes of temperature or barometric 
pressure will aggravate the symptoms. Laryngeal compli- 
cations are usually present. 

Diagnosis. — The history, and by urinalysis. 

Prognosis. — Fairly favorable, unless extensive morbid 
changes in the tissues have taken place. 

Treatment. — Practically the same as in the acute type, 
only more time will be required. 



&*•% 



4-o8 Nose, Throat and Bar. 

INFECTIOUS GRANULOMATA OF THE PHAR- 
YNX, NASOPHARYNX, AND TONSILS. 



Tuberculosis. 

Synonyms. — Tuberculosis of the pharynx ; Consumption 
of the pharynx. 

This is usually secondary, or may accompany pulmonary 
tuberculosis, but is very infrequent. 

Symptoms. — Unless a known pulmonary lesion exists, 
the early symptoms may be regarded as an acute or sub- 
acute pharyngitis. Later, local swellings resulting from the 
inflammatory exudate occur, and may involve the velum, 
uvula, faucial pillars, or any portion of the pharyngeal tis- 
sues. The tonsils may be affected, either primarily or sec- 
ondarily. The disease usually extends downwards more 
rapidly than upwards. Infiltration and thickening of the 
tissues produces a variety of symptoms. The thickened soft 
palate, by not properly closing the nasopharynx during the 
act of swallowing, may permit food or fluids to enter the 
nasal cavities. There is also a tendency for the mucus or 
mucopurulent material to accumulate and become inspis- 
sated. When the uvula is thickened, it may cause a short, 
hacking, irritative cough. Usually coincident with the 
swelling there will be seen miliary tubercles as small yellow- 
ish spots beneath the surface of the membrane. After a 
variable period these soften, rupture, and form minute ul- 
cers, often scarcely noticeable. Their outline is irregularly 
rounded, the ulcers shallow, the floor covered with a grayish 
secretion. There is no well defined areola of inflammation, 
and there is a general pallor of the membrane. 

The ulcerative process rapidly increases, each focus ex- 
tending in depth as well as laterally. These areas coalesc- 
ing, soon cause extensive ulcerative tracts. In some cases 
there will be spaces of unaffected tissue between the ulcer- 
ative areas, presenting the "moth-eaten" appearance. Oc- 



Tuberculosis. 409 

casionally miliary tubercles may be seen in the floor of the 
ulcers, or masses of granulations at their edges. Irritation 
of these surfaces may cause bleeding. 

As the disease progresses, the secretion becomes more 
profuse, tenacious, and slimy, and may interfere with res- 
piration, or it may be wheezy. The ulceration rapidly 
progresses, and may result in complete destruction of the 
palatal soft tissues. The larynx or buccal cavity may be 
affected simultaneously, and aggravates the condition. In 
a few cases partial cicatrization may occur. A variable 
amount of pain is always present, its location depending 
upon the situation of the lesion. 

In the early stages the pain is described as a dry, 
parched, burning ache; this becomes later sharp and lanci- 
nating in character. The ear may be involved, especially 
if the lateral pharyngeal wall or faucial pillars be the seat 
of the active disease. Motion increases the pain, and the 
act of swallowing becomes more painful as the morbid 
process increases. The voice is muffled, and there is diffi- 
culty in clearing the throat. Cough is present and may be 
pulmonary, or the result of the pharyngeal lesion. In the 
latter case it is the dry, hacking, irritative form. The breath 
is fetid. The other symptoms are those caused by the pul- 
monary lesions which accompany or soon follow in this 
disease. 

Diagnosis. — Usually easy, but occasionally, prior to ul- 
ceration, it may be difficult. The chances of a mixed infec- 
tion must be remembered. 

Prognosis. — Unfavorable, as death usually follows 
within six months. 

Treatment. — Pharyngeal tuberculosis is seldom primary, 
but is usually secondary to laryngeal or pulmonary tuber- 
culosis. Local measures are for the alleviation of the pain 
resulting from the ulceration. Cocaine has been employed, 
but on account of its influence on the general system should 



4io Nose, Throat and Bar. 

be resorted to only in aggravated cases. Chloreton.e in- 
halant has afforded relief in some cases, and so far as noted 
without injurious effects. The salicylic acid wash will 
cleanse the tissues, and if three per cent carbolic acid is 
added, will cause some anesthesia of the tissues. The juice 
of the pineapple, as a spray, has given relief in some cases. 
Internally, the use of the remedies already given will be 
found most advantageous. 

Lupus. 

The generally accepted theory is that lupus is simply a 
local manifestation of tuberculosis. The scrofulous -diathesis 
appears to favor its appearance. It is seldom a primary 
affection of the pharynx, being usually secondary to nasal 
or buccal invasion, which in turn results from extension 
of the disease from the facial integument. Any portion of 
the pharyngeal tissues, tonsils, or faucial pillars may be 
affected. The progress is slow, but the loss of tissue ex- 
cessive. Men are most often affected. The disease appears 
usually under the age of thirty, and frequently is preceded 
by recurring attacks of pharyngitis. 

Pathology. — There is a cellular infiltrate into the deeper 
layers of the mucous membrane and underlying tissues. 
The infiltrate is in masses between the trabecular of con- 
nective tissue and glandular structure, and closely associated 
with a blood-vessel. Microscopically the characteristic ap- 
pearance of granulation-tissue, with numerous giant cells 
among the cellular elements, and a few tubercular bacilli. 
The later appearances are those of ulceration and extensive 
and rapid cicatrization, or infrequently absorption. Any 
portion of the pharynx, tonsils, or faucial pillars may be 
affected. 

Symptoms. — Usually there is not enough discomfort to 
cause the patient to seek aid until the disease has progressed 
for some time. There is little if any pain, and the pharvn- 



Lupus. 411 

geai functions are not materially interfered with unless the 
epiglottis is considerably involved, or there is much impli- 
cation of the tissues in the immediate vicinity of the Eu- 
stachian orifices. In the early stages the mucous mem- 
brane at the site of infection is livid, smooth, dry, or may 
be granular. Small, lighter colored points may be seen 
designating the location of typical lupus nodules. These 
soon show as miliary nodules varying from a millet seed to 
half a pea in size, and plentifully distributed over the af- 
fected surface, giving the appearance of a mamillated mem- 
brane. Their color is that of the surrounding membrane, 
they are smooth and soft to touch, easily penetrated, and 
painless. Occasionally there will be no external ulceration, 
but absorption of the inflammatory infiltrate may result in 
considerable loss of tissue. External ulceration is the rule, 
the nodules softening and breaking down, forming necrotic, 
slightly elevated foci. They present thickened, inflamed 
borders, and are covered with a grayish, glairy, tenacious 
secretion. These nodules may remain discrete, or coalesce. 

The ulceration is not as deep as in tertiary syphilitic 
lesions. The characteristic tendency to cicatrization after 
ulceration, is present. The changes in the pharyngeal struc- 
tures are usually extensive, and depend upon the location of 
the lesions and severity of the ulceration. The general 
health is not usually impaired. 

Diagnosis. — Generally easy. The slowness of the morbid 
process, shallow ulcers, and rapid cicatrization distinguish 
it from syphilis. The lack of improvement under anti- 
syphilitic treatment will be an aid. 

Prognosis. — Unfavorable, as many cases will grow grad- 
ually worse, no matter what measures are adopted. 

Treatment. — Complete removal of diseased tissue by 
curettement or the galvano-cautery. Caustic drugs should 
not be employed, as their action is difficult to control. The 
salicylic acid wash is valuable in these cases. Internally 



412 Nose, Throat and Ivar. 

the use of phytolacca, jaborandi, or Hydrastis may be indi- 
cated. In severe cases, where the laryngeal structures are 
involved, tracheotomy may be required. 

Syphilis. 

Syphilis of the pharynx may be either acquired or con- 
genital. The former is found more often after puberty, 
while the congenital may manifest itself during the first few 
months after birth (secondary), or usually not until after 
the age of fifteen (tertiary), the late hereditary syphilis. 
The pharynx generally is markedly affected in syphilis, and 
the symptoms are characteristic. 

Primary. — After the genitalia, the lips, tonsils, and 
pharynx are the most frequently affected regions of the pri- 
mary lesions. The infection may result from kissing, in- 
fected drinking cups, especially in public places, surgical 
instruments, pipes, etc. Infection from syphilitic nurses 
have been reported, and among sexual perverts is not in- 
frequently found. The primary sore in these regions is mere 
often found in females. The tonsils seem to be the favorite 
location. One only may be affected, but both may be. 
Faulty diagnosis is probably responsible for more cases not 
being reported. 

Symptoms. — Usually not severe, nor long continued. 
The character of the primary lesion is practically the same 
as on the mucous membrane of the female genitalia. When 
the pharyngeal surfaces are the location of other morbid 
conditions, the diagnosis is difficult. The infection may be 
at any point of abrasion. The tonsil is the usual location, 
and palpation with a probe may determine the hard base. 
There may be a slight inflammation of the tonsil ; or con- 
siderable ulceration instead of the typical lesion. Infre- 
quently the typical sore may be covered with a false mem- 
brane, which is easily removed and reveals the chancre. 
The entire gland is inflamed, hardened, and enlarged. Dur- 



Syphilis. 413 

ing the continuance of the sore, pain is variable, but there 
is more or less difficulty in swallowing, local tenderness, and 
the usual annoying symptoms of sore throat. 

When the initial lesion is on the posterior pillars, there 
is usually pain referred to the ear, and if there is occlusion 
of the openings of the Eustachian tubes ear symptoms will 
develop. There will also be the characteristic indolent swell- 
ing of the lymphatics at the angle of the jaw and sterno- 
cleido-mastoid muscles, either of one or both sides depend- 
ing upon the site of the sore. The skin covering the glands 
is not discolored; the glands can be felt as hard, movable 
bodies, and without a tendency to suppurate. 

Secondary Lesions. — These may be of either the ac- 
quired or hereditary disease. If acquired, they appear with 
other systemic manifestations, usually six or eight weeks 
after the infection. When hereditary, the appearance is 
usually within two months after birth. 

Symptoms. — The most prominent are erythema, mucous 
patch, or occasionally superficial ulceration. Erythema usu- 
ally is the first noticed, and may be confined to a limited 
area, or cover the entire visible pharyngeal wall. None of 
the pharyngeal and tonsillar surfaces are immune, but it is 
infrequently found above the level of the hard palate. There 
may be a diffuse, dusky, dirty reddening, but more often 
there are small, sharply defined, dusky red areas with prac- 
tically normal tissue separating them, giving a mottled ap- 
pearance which is pathognomonic. Accompanying the ery- 
thema, cough, a dry or tickling sensation, and dull pain may 
be present. The usual symptoms of a catarrhal pharyngitis 
may be noted. The erythema generally persists during the 
cutaneous eruption, but readily yields to specific medication. 

Mucous patches follow the erythematous condition, the 
time of their appearance varying. These may be located on 
any portion of the pharyngeal, tonsillar, or faucial surfaces, 
the anterior portions of the latter being most frequently 



414 Nose, Throat and Ear. 

affected. The patches commence as dark, dusky-red 
rounded elevations, clearly denned, and soon soften, super- 
ficial necrosis following, forming rounded areas with well 
defined borders slightly elevated above the surrounding 
membrane, and covered with a grayish and poisonous secre- 
tion. Surrounding each ulcer is a zone of inflamed tissue. 
The ulcers are usually not deep, and there is little tendency 
to spread, cicatrization following with a fibrous scar. A 
fetid breath is often present, but there is slight discomfort 
resulting from the lesions. Occasionally there is a dispo- 
sition to superficial erosion of the membrane, which follows 




Fig. 90. Syphilitic perforating ulcers of velum. 

a whitening or cloudiness of the upper layers, but is not 
severe. A recurrence is liable to occur if treatment is too 
early discontinued. 

Tertiary. — These lesions in the acquired form may be 
found at about seven years, but usually not until twenty or 
more years after the infection. In congenital syphilis they 
seldom appear before the age of fifteen. The pathognomonic 
feature is the gumma, with its attendant destruction of tis- 
sue and marked changes in the structures. Infrequently 
there will be extensive malignant ulceration of the entire 
pharynx, which soon proves fatal. Any of the pharyngeal 
and contiguous structures may be affected. 



Syphilis. 415 

Symptoms. — The gumma are smooth, sharply defined, 
and there is no marked discoloration of the membrane cover- 
ing the mass. After a variable- period ulceration occurs. 
This is deep and extensive, the destruction of tissue being 
considerable, destroying not only the pharyngeal, but the 
tonsillar, faucial, and even the velum tissue, the latter either 
sloughing, or being extensively perforated. Some cases 
have been seen in which the process has extended to the 
deep vessels of the neck, fatal hemorrhage occurring. The 
bony tissues of the posterior pharyngeal wall and vault are 
often affected. The invertebral discs and bodies of the ver- 




FiG. 91. Hereditary tertiary ulceration of velum. 

tebrae may necrose, exposing the spinal cord. The base of 
the skull may be exposed, and through necrosis, the brain 
be exposed. When such a condition exists, the fetor is very 
marked. The discharge consists of a disgusting, dirty, 
purulent material, containing particles of necrosed bone. 
Sequestra may be formed, and palpation with a probe will 
give the characteristic sensation. Healing may occur, even 
without specific treatment, of thick fibrous and contracting 
cicatrices. As a result of this destructive process, the en- 
tire pharynx may be deformed, the nasopharynx practically 
destroyed, as well as the soft palate. Adhesions may result, 
partially or completely occluding the pharyngeal spaces. 



416 Nose, Throat and Ear. 

This necessarily impairs the pharyngeal functions. The dis- 
comfort of the patient is not in proportion to the amount of 
the destructive process. 

Diagnosis. — In the secondary and tertiary forms it is 
comparatively easy, as the lesions are characteristic, and 
systemic conditions will be an aid, even without a specific 
history, which is not always easily obtained. The ready 
response to specific treatment will soon clear all doubts. 
The primary lesion is more difficult to diagnosticate, and 
sometimes may not be made until secondary manifestations 
present. 

Prognosis. — This will depend considerably upon the gen- 
eral health. Proper treatment' will usually result* in a cure 
if employed early, but after severe structural changes have 
occurred the prognosis is more unfavorable. The tertiary 
form is the most intractable. 

Treatment. — Practically the same as in syphilitic rhinitis. 

Glanders. 

Synonyms. — Equinia; Malleus humidus. 
The etiology, pathology, symptoms, etc., are practically 
the same as in the nasal cavities. 

Actinomycosis. 

Etiology. — The ray-fungus is credited as the cause of 
this condition. This fungus is only found in the small yel- 
lowish masses mixed with the purulent discharge. Within 
the morbid tissue the appearance of the fungus is that of 
small clusters of irregularly sized cells, which if cultivated 
on artificial media, appear as tangled masses of threads. 
Any of these forms are virulent. The disease is similar to 
glanders, in being primarily one affecting the higher ani- 
mals, the bovine race most frequently, but is easily com- 
municated to man. Actinomycosis is infrequently seen in 



Actinomycosis. 417 

the pharynx and tonsils, but it may occur either primarily 
or secondarily. 

Pathology. — The invasion of the fungus results in the 
development of a granulation tumor, the appearance of 
which is similar to the local manifestation of tuberculosis. 
There will be found small, round cells, together with giant 
and epithelioid cells. Later there will be inflammatory re- 
action, resulting in proliferation of the tissue-elements and 
the formation of morbid tissue, which is readily mistaken 
for sarcomatous material. Suppuration follows, which is 
extremely stubborn. Infection is transmitted by the lym- 
phatic and vascular systems, usually the latter. The disease 
is chronic in character. 

Symptoms. — Two types are to be considered — those in 
which there is local swelling and ulceration, and the cases 
where there is a general systemic disturbance from the sup- 
purative products, or a metastatic action similar to any 
chronic suppuration. The local symptoms develop slowly, 
and are .similar to any gradual interference of the functions 
of the pharynx. At the point of infection a small, round, 
and reddened elevation is seen. The surrounding tissues 
will be swollen, and in a short time the permanent character- 
istics of a chronic condition result. The swelling is clearly 
defined, irregular, firm to probe-palpation, not hypersensi- 
tive, and slowly increases in size. 

Suppuration and sinus formation follow. The discharge 
from the sinuses is steady, more or less purulent, and con- 
tains small yellowish masses made up principally of the ray- 
fungus. The sinuses are deep, and implicate considerable 
tissue. The disease does not often extend beyond the points 
of infection. Pain is dependent mostly upon the location 
and extent of the swelling. It is usually a constant, heavy, 
local aching, but may be variable. The breath may be fetid 
and gastric complications may occur. Metastatic develop- 
ment in the lungs, alimentary tract, or in any part of the 
27 



4i 8 Nose, Throat and Ear. 

body may occur. The systemic manifestations will depend 
upon the severity of the invasion, but a fatal termination 
from exhaustion or complications usually follows. 

Diagnosis. — Can only be made, so far as now known, 
by a microscopic examination revealing the ray-fungus, and 
confirmation by inoculating some animal. 

Prognosis. — Unfavorable, as the disease is seldom recog- 
nized until too late. 

Treatment.— No constitutional treatment is efficacious, 
although large doses of potassium iodide have been reported 
as curative. When possible, the extirpation of diseased tis- 
sue offers the most satisfactory results. 

Retro-Pharyngeal Abscess- 

This results from the formation of pus, and may be lo- 
cated high up behind the velum, or by burrowing may in- 
vade the cervical or mediastinal regions. In infancy or 
early childhood the lymphatic system is usually at fault, 
or may be the cause. In adults the pus is in the cellular 
tissues. As the disease differs according to the age, it is 
most convenient to divide it into two classes, infancy and 
adults. 

Abscess During Infancy. — In these cases it is usually 
at the side, seldom being in the center of the pharynx. The 
disease is most frequently found in the children of syphilitic 
or tubercular parents. The probability is that it is secondary 
to infection of the lymphatic glands. The loose structure 
of the pharyngeal tissues favors the accumulation and easy 
burrowing of pus in nearly any direction. The disease is 
usually insidious in its course, often no symptoms being 
noticed until dyspnea or attacks of choking on attempting 
to swallow are present ; the condition being more like that 
of a chronic abscess. Occasionally there are clinical symp- 
toms calling attention to the pharynx, even in the early 



Retropharyngeal Abscess. 419 

stages, depending upon the location of the abscess. Cough 
and change in the voice may be present. 

Abscess in Adults. — The onset is usually marked, prob- 
ably on account of the involvement of the cellular tissue. 
Pain referred to the fauces and increased on swallowing 
is usually first complained of, the pain being out of propor- 
tion to the evident amount of inflammation. Fever is usu- 
ally present and may become hectic in character. The loca- 
tion of the abscess will largely determine the symptoms. A 
deep-seated, constant pain is present, and increases until 
rupture or surgical interference occurs. Dyspnea is not 
often present. 

Diagnosis. — Inspection will reveal an asymmetry of the 
tissue, the bulging portion being bright red and somewhat 
glazed. Palpation will determine fluctuation, and probe 
palpation will cause a bleaching of the tissues, the color re- 
turning slowly. In children there may be but slight evi- 
dences of inflammation surrounding the abscess, the diag- 
nosis depending upon the recognition of the swelling lessen- 
ing the pharyngeal space. In children, croup, bronchitis, 
or edema of the larynx may be mistaken for this disease. 
In adults the possibility of an aneurism in this region must 
be remembered. 

Prognosis. — When acute, the abscess usually ruptures 
in from five to ten days, unless recognized and opened pre- 
viously. Spontaneous rupture during sleep, with some of 
the pus entering the larynx, may cause broncho-pneumonia 
or asphyxiation. In children an early recognition of the 
disease will usually be favorable. Complications caused 
by, or as a sequence of the abscess, may result fatally. Ab- 
scess resulting from, or as a symptom of vertebral disease, 
is insidious, and usually fatal. When healing takes place 
the inflammatory tissue may appear as a nodular mass on 
the pharyngeal wall, and later produce a constant irritation. 

Treatment. — Evacuation of the abscess should always be 



420 Nose, Throat and Ear. 

done as soon as recognized. If pus has not formed when 
the swelling is discovered, scarification or multiple puncture 
will often afford relief. In opening the abscess, the patient's 
head should be lowered to prevent the pus entering the air 
passages. The use of the autospray of cocaine two per cent 
will be useful. When the lymphatic glands are the site of 
abscess formation, the incision should be made externally 
along the anterior border of the sterno-cleido-mastoid mus- 
cle, care being taken not to injure the blood-vessels of this 
region ; general anesthesia is preferable. 

Internal Medication. — Lime in some form, Phytolacca, 
iris, arsenic iodide, and when the bony structures of the 
spine are involved, gold and sodium chloride, silicea, or po- 
tassium iodide. 

Urticaria. 

Urticaria may cause edema of the glottis in connection 
with the pharyngeal manifestation. The disease is seldom 
seen. 

Ecthyma, pemphigus, erythema multiformum and exu- 
dative have been reported. 

Herpes. 

Synonyms. — Pharyngitis herpetica; common membran- 
ous sore throat ; aphthous sore throat ; benign croupous 
angina ; simple membranous sore throat. 

In this disease there are numerous small, discrete, erup- 
tive points distributed over the fauces and pharynx. These 
disappear after a variable period of a few days or weeks, 
then recur. This may last an indefinite time. 

Etiology. — Obscure, but evidently the result of an irri- 
tation or inflammation affecting the terminal nerve fila- 
ments. The primary cause may be disturbances of the ali- 
mentary tract, systemic diatheses, or diminished eliminative 
action. It may accompany or follow febrile states, and in- 
frequently has been noted as coincident with uterine affec- 



Pharyngomycosis. 421 

tions. The implication of the trifacial nerve is usually given 
as a cause. 

Symptoms. — Usually sudden in onset, with sometimes 
a slight fever, discomfort, or pain. A general feeling of a 
subnormal condition and gastric wrongs prior to the erup- 
tion may be present. One or both sides may be affected. 
Usually one of the first symptoms is a sensation of dryness, 
soon followed by pain radiating to the ears, and sometimes 
to the nasal chambers or larynx. Herpetic eruption of the 
lips will often be found. The pain may cause difficulty in 
swallowing, but this will depend largely upon the location 
of the lesions. On inspection there will be found round 
or oval discrete areas on the uvula, velum, faucial pillars, or 
pharynx. Usually vesicular and in groups, or scattered 
over the surfaces. These soon become excoriated, and cov- 
ered by a thin, yellowish-white, easily removed false mem- 
brane. The exposed surface bleeds easily. Sometimes 
there will be little, if any, change in the mucous membrane. 
There may be at the same time an involvement of any muco- 
cutaneous surface. 

Diagnosis. — Usually easy, if the symptoms are carefully 
noted. 

Prognosis. — The tendency to recur must be remembered, 
as well as that it renders the patient more susceptible to 
infectious diseases. 

Treatment. — Saline cathartics to empty the bowels thor- 
oughly. Rhus tox., apis, or bryonia are usually indicated. 
The use of fresh chocolate creams will be found useful in 
allaying the irritation. Locally the chloretone inhalant, or 
a sedative spray, may help relieve. 

Pharyngomycosis. 

The development of Leptothrix spores in the follicles of 
the pharynx, tonsils, etc., produce the condition called my- 
cosis. 



422 Nose, Throat and Ear. 

Etiology. — The primary cause is the Leptothrfx in the 
secretions of the mouth, which find in an acid state or an 
acute inflammation of the pharyngeal mucous membrane or 
tonsillar crypts, a favorable nidus for development. A sub- 
normal systemic state, or local inflammatory condition, is 
usually present. 

Pathology. — Leptothrix belongs to the schizomycetes 
class of fungi, and is present in nearly all locations contain- 
ing decomposing vegetable material. The changes in the 
affected membrane are generally superficial, consisting in 
thickening of the upper epithelial cells, coagulation-necrosis 
with desquamation following. The crypts are distended 
with the fungoid growth. Infrequently the submucosa and 
connective tissues are affected. The patches are white, and 
look like mould. 

Symptoms. — These are due more to mechanical irritation 
than to inflammatory action. A slight cough, and stiffness 
of the parts, more marked on swallowing, may be noted. 

Diagnosis. — The primary location is usually the faucial 
or lingual tonsil, and may invade the pharynx, nasopharynx, 
velum and uvula, and the tongue. It may be differentiated 
from the cheesy lacunar masses, by leaving a bleeding sur- 
face when removed. The material is very similar to that 
of keratosis, but in the latter the masses are firmer and more 
difficult to remove. Some hemorrhage occurs in either case. 
A microscopical examination will establish the diagnosis. 

Prognosis. — Chronic course. 

Treatment. — Curettement and the use of a saturated so- 
lution of salicylic acid in thuja; tr. iodine or a 20 per cent 
chromic acid. Keep the mouth well cleansed by the use of 
a saturated solution of boric acid. In extreme cases the 
galvano-cautery or removal of the tonsils. 



Keratosis. 423 

Keratosis. 

S ynony ^.-^Hyperkeratosis. 

In this disease horn-like whitish tufts are formed, the 
usual location being in and around the tonsils, lateral phar- 
yngeal walls, and base of the tongue. Infrequently may 
occur on the pharyngeal vault. Constitutional disturbances 
do not appear to have an influence. Gray, of Glasgow, re- 
ports a rare case affecting the larynx, in which the appear- 
ances were those of tuberculosis, but clinical symptoms were 
absent. 

Etiology. — The disease is usually seen between the ages 
of twelve and thirty-five. Sex does not seem to be a factor. 
Neither climatic nor social conditions appear to have an in- 
fluence. Occupation and hygienic surroundings are also 
eliminated as factors. Some inflammatory state of the nasal 
or nasopharyngeal tissues will often be found. The con- 
dition, according to Siebenmann and Kyle, is that it is sub- 
epithelial. 

. Pathology. — From microscopic examinations the morbid 
process appears to extend from below towards the surface. 
The keratosis, whatever its cause, seems to be dependent 
upon the subepithelial structure and the accompanying de- 
generative processes. The fibrous bands extending from the 
subepithelial tissue, penetrating and obliterating the base- 
ment membrane, and extending to the epithelial surface, are 
probably organized connective-tissue papillae crowded up- 
ward through the epithelial layer, and become horn-like on 
the surface. The degenerative changes seem to be largely 
hyaline. 

Symptoms. — These are variable, depending largely upon 
the site of the growth. When located in the tonsil, symp- 
tom's are usually absent, the presence of the tufts usually 
being discovered accidentally. If in the faucial region, a 
sensation of stiffness and scratching may be complained of, 



424 Nose, Throat and Ear. 

which is usually aggravated on swallowing and after eating. 
When the faucial pillars are the location, the sensation of 
a foreign body is usually complained of. When located on 
the base of the tongue, there will be more or less "cough and 
hawking to clear the throat. 

Several forms occur, probably not distinct types, but 
varying according to the location and duration of the proc- 
ess. There are the minute, distinctly white spots, not ele- 
vated above the mucous membrane ; the broad, white masses 
elevated above the mucous membrane, usually found upon 
the pillars and lateral pharyngeal walls ; and the conical or 
triangular horny projections. The latter are the most fre- 
quent. The growths are small, hard, and adherent to the 
mucosa, being removed only by considerable effort, and do 
not disintegrate when removed. The most dense are from 
the base of the tongue and tonsillar crypts. Those about 
the faucial isthmus are often surrounded by a pultaceous 
material, The usual location of what is termed keratosis 
pharyngei is Waldeyer's lymphatic chain. 

Diagnosis. — Febrile symptoms are absent. Spontaneous 
resolution often occurs, the time being variable. The tufts 
are usually a pearly, waxy white, and firm, and microscopic 
sections can be made. Sometimes the disease presents 
wedge-like, triangular projections, extending into the paren- 
chymatous coats. These are of a yellowish, glassy appear- 
ance. The tufts are larger, and entangled with epithelial 
plates and granular debris. 

Treatment. — The actual cautery or thorough curette- 
ment are the most satisfactory. This should be followed 
by the use of salicylic acid wash or 20 to 40 per cent chromic 
acid. 

Pulsating Arteries of the Pharynx. 

Anomalous configuration of the posterior lateral pharyn- 
geal walls may be attended by anomalous vascular condi- 
tions. The branches of the ascending pharyngeal may be 



Anemia of the Pharynx. 425 

enlarged, or even the ascending pharyngeal artery may be 
distinctly seen in the pharyngeal wall. As muscular support 
is missing, a pulsating artery results. Another factor is the ' 
superficial location, and the frequent tendency to inflamma- 
tion of the mucous membrane. Aneurism of the vessel is 
frequently found. Pulsating arteries are infrequent, but 
when present there is usually the sensation of a movable 
foreign body in the pharynx, and a constant desire to re- 
move it by efforts to clear the throat. Rupture of the aneu- 
rism may cause an excessive hemorrhage. Treatment is 
not of much value. 

Anemia of the Pharynx. 

In general anemia there is a subnormal systemic con- 
dition, and through the lack of tonicity, connective-tissue 
relaxation occurs. In tissue lacking support, as is the case 
practically when located on bony structure, there is exos- 
mosis from the arterial system, and retardation of the 
venous circulation from the , same cause, as well as some 
from the veins. As the vascular supply to the pharynx is 
considerable, it is to be expected that this region will have 
some exhibition of the systemic disturbance. The tissues 
may be somewhat edematous, but pale and flabby looking. 
Dilated, tortuous vessels will be seen on the surface and 
within the tissue. Relaxation of the velr.m, palate, and 
elongation of the uvula result from the morbid condition. 
This causes an additional irritation through mechanical 
means.' The secretion is profuse, and usually watery. The 
symptoms are very much like those of the early stages of 
simple chronic pharyngitis. No decided pathological 
changes occur. Anemia is most frequently seen in females. 

Symptoms. — A sensation similar to that of a foreign 
body in the throat, and a constant desire to swallow. 

Treatment. — Must be constitutional. 



426 Nose, Throat and Ear. 

Neuroses of the Pharynx. 

I. Anesthesia. 2. Hyperesthesia. 3. Paresthesia. 4. 
Neuralgia. 5. Neuroses of Motion, (a) Spasm. (b) 
Paralysis. 

Anesthesia. — This is infrequent. A bolus of food is 
not felt, and particles of the food remain in the pharynx, or 
may enter the larynx and lower respiratory tract. 

Etiology. — Morphine, large doses of bromides, or local 
anesthetics produce a temporary anesthesia. A nervous 
anesthesia is usually the result of ulceration, fibrous-tissue 
formation destroying the nerve terminals. It may occur 
from a progressive bulbar paralysis.- In hysteria, occasion- 
ally in general paralysis of the insane, epilepsy, typhus fever 
and cholera, it may be found. 

Prognosis. — The cause will determine the prognosis, 
which is unfavorable in extensive cicatrization or progress- 
ive bulbar paralysis. 

Treatment. — Nux, strychnine, ignatia, Pulsatilla, or the 
galvanic current. Sometimes nourishment must be admin- 
istered by the stomach-tube. 

Hyperesthesia. — This is quite frequently found. In 
acute inflammation, among excessive users of tobacco or 
alcoholics, it is also often present. Elongation of the uvula, 
hysteria, and neurasthenia may cause it. In some cases no 
factor can be discovered. 

Treatment. — Pulsatilla, passiflora, ignatia, or bromides 
may be required. 

Paresthesia. — Abnormal pharyngeal sensations may 
simulate cold, heat, a foreign body, or a swelling. 

Very often after the removal of a foreign body from the 
pharynx, the patient will insist that something remains. 
This is due to irritation of the nerve terminals, which con- 
tinues for some time. In hysterical persons abnormal sen- 
sations are frequent. Abnormal states of the follicles of the 



Neuroses of Motion. 42^ 

pharyngeal, faucial; or lingual mucous membranes may be 
a factor in this condition. " 

Prognosis. — Guarded. 

Treatment.— Enlarged follicles should be punctured and 
the contents expressed. When of neurotic origin, the treat- 
ment must be directed to the^ systemic condition. 

Neuralgia. — This results from the same causes as -pares- 
thesia, but actual pain is present. The actual cause of neu- 
ralgia elsewhere may produce pharyngeal neuralgia. In 
anemic or chlorotic persons it may be bilateral or unilateral. 

Treatment. — Locally sedative applications. Systemic- 
ally, removal of the exciting cause if it can be determined. 

Neuroses of Motion. 

Synonyms. — Clonic spasm of the pharynx; Pharyngeal 
nystagmus. 

(a) Spasm. — Acute faucial inflammation, hydrophobia, 
lyssophobia, cerebral lesions, chronic pharyngitis, hysteria, 
or epilepsy may be factors. 

Spasmodic ejection of food in deglutition may occur. 

A differential diagnosis must be made from stricture or 
paralysis of the esophagus, or paralysis of the pharynx. 
The use of an esophageal bougie will aid in the diagnosis. 
The spasm may be intermittent, and continue for a variable 
period, even months, necessitating rectal feeding. 

Treatment. — No general line of treatment can be fol- 
lowed. A careful investigation as to the cause, and the 
treatment of this is necessary. 

(b) Paralysis. — This may be of one or both sides, and 
one or all of the constrictors affected. 

Etiology. — Myelitis, either acute or chronic, embolism, 
hemorrhage, tumors, basilar meningitis, cerebrospinal men- 
ingitis, syphilis, sunstroke, tuberculosis; or any condition 
which implicates the governing nervous areas of the phar- 
ynx, may cause or simulate this condition. It may be asso- 



428 Nose, Throat and Ear. 

ciated with facial paralysis, and is not infrequently found 
following diphtheria. When it occurs during the course of 
acute febrile diseases the prognosis is bad. It may be an 
early symptom of what Duchenne terms Glossolabiolaryngeal 
paralysis or progressive bulbar paralysis. The exciting 
cause may affect the central point, along the course of the 
nerve, or its periphery. 

Symptoms. — Difficulty on swallowing is the most 
marked. This causes an accumulation of saliva which 
dribbles from the mouth. The effort to swallow is accom- 
panied by contortions of the facial muscles and also those 
of the neck. Fluids often enter the trachea, causing cough 
or spasm of the glottis, even though deglutition is appar- 
ently successful. The expression of the face in attempted 
deglutition is that of pain and sorrow. When the velum 
palati is affected, food may be forced into the postnasal 
space. 

In acute bulbar paralysis the pharyngeal symptoms are 
often unnoticed, on account of the disturbances elsewhere. 
Dizziness, headache, erratic walking, faulty phonation, and 
impaired respiration follow rapidly to a fatal ending, as a 
rule. In progressive bulbar paralysis the symptoms usually 
begin with disturbances of the tongue, lips, pharyngeal, and 
laryngeal constrictors in rapid succession. Difficulty in 
speech finally becomes a mumbling sound. Atrophy of the 
tongue occurs, which renders mastication and deglutition 
difficult. There will be an accumulation of food between 
the cheeks and gums. It will be impossible to produce 
dental or labial sounds. Saliva runs from the corners of 
the mouth or may pass into the larynx, causing violent spas- 
modic gagging and coughing, or even a septic pneumonia. 
Diphtheritic pharyngeal paralysis may result from central 
toxemia or peripheral nerve-necrosis, and may be bilateral 
or unilateral. Dysphagia, regurgitation of food through the 
nose, impairment of the sense of smell and taste, food pass- 



Foreign Bodies in the Pharynx. 429 

ing into the larynx, and inability to eject the accumulated 
mucus, are the prominent symptoms. 

Diagnosis. — The history and symptoms will determine 
the condition. 

Prognosis. — When caused by diphtheria, or accompanied 
with facial paralysis, the prognosis is fairly good. When it 
occurs late in febrile diseases, or from acute bulbar or pro- 
gressive bulbar paralysis, it is usually fatal. 

Treatment. — This will depend upon the exciting cause, 
discrimination in determining this being essential. 

Foreign Bodies in the Pharynx. 

Various objects may become lodged in the pharyngeal 
or surrounding tissues, and sometimes are very difficult to 
locate and remove. The form of the object has more to do 
with its retention in this region than the size. The intro- 
duction of a foreign body may be either accidental or with 
food. Pins, fishbones, fragments of bone from steak or 
roasts, in fact almost any object may be found lodged in the 
pharyngeal region. Sharp or pointed objects frequently 
penetrate the spongy tissue of the faucial or lingual tonsils. 
Small objects, especially irregular in outline, may become 
lodged in the pyriform sinus, the posterior pharyngeal wall 
or at the esophageal entrance. Smooth objects may stop 
at the cricoid eminence. 

Sharply pointed bodies, when allowed to remain, may in- 
duce inflammation and suppuration. In some cases they 
may pierce the tissues and become encysted, or even migrate 
to some other location. 

Symptoms. — Usually pain in the invaded region, but this 
may be referred to some other point. Cough and retching 
are sometimes present. The symptoms produced by the 
larger bodies will depend upon their location. If low in 
the pharynx, near or within the esophageal entrance, there 
will be pain on swallowing. When there is pressure against 



43o Nose, Throat and Ear. 

the larynx, the voice will be affected. In children convul- 
sions may occur, and in adults convulsive action of the 
fauces. 

To locate the foreign body, the patient should be in- 
structed to open the mouth naturally, and an inspection 
made. Then the tongue depressor should be used, and if 
failure to locate the body results, the mirror may be used. 
The use of the autospray of two per cent cocaine will often 
be necessary, especially when the object can not be dis- 
covered by the methods described. After anesthesia, the 
index finger should be introduced and passed carefully 
around all, the structures within reach. In some cases cotton 
loosely wrapped on a probe may engage the body. Curved 
forceps may be required for the removal of the offending 
substance. Considerable ingenuity is sometimes necessary 
to dislodge the foreign body. After its removal there is 
often a persistent sensation of irritation. A sedative solu- 
tion will often aid in allaying this sensation. 



CHAPTER XIX. 
DISEASES OF THE LARYNX. 

Malformations and Deformities. — (i) Congenital. 
(a) Stenosis. (b) Dilatation or Pouch (Laryngocele). 
(c) Hypertrophies. (2) Acquired, (a) Stenosis. (1) 
Tubercular. (2) Syphilitic. (3) Lupus. (4) Traumatic. 

Acute Inflammatory Diseases. — (1) Acute Catarrhal 
Laryngitis. (2) Acute Catarrhal Laryngitis in Systemic 
Diseases. (a) Erysipelas, (b) Measles, (c) Scarlet 
•Fever, (d) Typhoid, (e) Typhus, (f) Influenza, (g) 
Miasmatic Epiglottitis. (h) Rheumatism. (3) Acute 
Laryngitis in Children. (4) Laryngismus Stridulus, (a) 
Spasm in Children, (b) Spasm in Adults, (c) Spasmodic 
Laryngitis. (5) Acute Epiglottitis. (6) Traumatic Laryn- 
gitis. (7) Suppurative Laryngitis. (8) Rheumatic Laryn- 
gitis. (9) Edematous Laryngitis, (a) Chronic Edema. 
(10) Membranous Laryngitis, (a) Croupous, (b) Fi- 
brinoplastic. (11) Hemorrhagic Laryngitis. Chondritis 
and Perichondritis. 

Simple Chronic Inflammations. — (1) Simple Chronic 
Laryngitis. (2) Follicular Laryngitis. (3) Dry Laryn- 
gitis. (4) Cyanotic Laryngitis. (5) Hyperplastic Laryn- 
gitis. Anemia. Hyperemia. Singers' Nodules. 

Specific Inflammations. — (1) Syphilis. (2) Tuber- 
culosis. Laryngeal Hemorrhage. Foreign Bodies. Pro- 
lapse of Laryngeal Ventricles. Neuroses. 

Malformations and Deformities. 

The form of the larynx varies, but when much deviation 
from the standard occurs it is called abnormal. The vari- 

43i 



432 Nose, Throat and Bar. 

ations from congenital conditions are usually due to hered- 
itary taints. In some instances an extremely small larynx 
may occur. 

Congenital Stenosis. — Defective development of the lar- 
ynx is frequently present when there are malformations of 
the genital apparatus, lungs, trachea, or bronchi. Bands 
or webs of tissue extending across the glottis are most often 
found, and are most frequent in the anterior commissure. 
In the interarytenoid region a cleft may be present, affecting 
the cricoid cartilage, epiglottis, and also the palate. Occa- 
sionally there may be an incomplete separation of the vocal 
cords at the anterior portion, and not interfere with pho- 
nation. 

Treatment. — Enlarged tonsils, nasal polypi, adenoids, or 
septal deviations impairing respiration, should be corrected. 
In some the use of an intubation tube, which may be worn 
for a variable period, will suffice, but in some cases the web 
must be divided. The tube is either worn constantly or in- 
troduced at times after this procedure. Tracheotomy may 
be necessary in some cases. 

Dilatations or Pouches. — Laryngocele of the laryn- 
geal lining may be the result of congenital anomalies, or 
may appear after necrotic action of the cartilage, the pouches 
resulting from exterior communication. 
I Hypertrophies. — In the anterior commissure, or pro- 
jecting from the vocal cords, projections of normal tissue 
are sometimes found. They may be acquired or congenital, 
and are really hyperplasias. The cause is unknown. 

Symptoms. — Impaired phonation, and often a persistent 
metallic cough, or spasm of the glottis may be present. 

Treatment. — Abnormalities of the upper respiratory tract 
interfering with free respiration should be removed. Oper- 
ative measures, unless contraindicated, should be insisted 
upon. Local applications are usually harmful. 

Acquired Stenosis. — A constant contraction of the 



Malformations and Deformities. 433 

laryngeal aperture may result from traumatism or sys- 
temic diseases. (a) Cicatricial narrowing or exuberant 
granulation, resulting from injury by foreign bodies, at- 
tempted suicide by cutting the throat, the swallowing of 
caustic or hot liquids, or inhalation of steam, may cause 
stenosis. The prognosis is unfavorable, as loss of phonative 
action, as well as extensive cicatrization or edema, may 
prove fatal. Tracheotomy is necessary when the stenosis 
endangers life. The operative measures will vary with the 
severity of the case, (b) Laryngeal syphilis may cause 
stenosis. Chronic edema during any stage of the disease 
may cause the contraction. 

Sudden acute marked dyspnea in children is frequently 
a syphilitic edema. The usual syphilitic stenosis results 
from cicatricial bands or webs connecting the vocal cords, 
ventricular bands, or different parts of the larynx. 

Symptoms. — Hoarseness or limitation of the register of 
the voice. Sometimes impaired respiration. According to 
Lennox Browne, intermittent attacks of dyspnea for many 
years is characteristic of syphilis. There is a spasmodic 
cough, scanty expectoration, and often pain and difficulty 
in swallowing. 

Treatment. — Usually mechanical. 

Tuberculous Stenosis is not often cicatricial, healing 
seldom occurring. Edema is to be feared. 

Lupus. — Contraction of the 'laryngeal aperture from 
lupus lesions is usually a matting together of the parts, 
which may be so extensive as to leave only a pinhole open- 
ing. The tissues usually are anemic, excepting where red- 
dish nodules show an acute inflammation. 

Symptoms. — Usually the symptoms are not in propor- 
tion to the appearance of the lesion. There is not often 
much difficulty in respiration and deglutition, or much 
change in the voice. A lupus web is usually supraglottis 
while in syphilis or tuberculosis the tissues are usually af- 
28 



434 Nose, Throat and Ear. 

fected at the level of or below the aperture. Laryngeal 
lupus is usually secondary. 

Prognosis. — Not as unfavorable as in syphilitic or tuber- 
cular lesions, as slow, spontaneous absorption may occur. 
Later tuberculosis may be a complication. 

Treatment. — Operative. 

INFLAMMATORY DISEASES OF THE LARYNX. 
Acute Catarrhal Laryngitis. 

Synonyms. — Acute catarrh of the larynx ; Laryngorrhea ; 
Spurious Croup. 

In this disease there is an acute catarrhal inflammation 
of the laryngeal mucous membrane, which produces a slight 
dyspnea and hoarseness. These symptoms are more pro- 
nounced in children than in adults, although seldom endan- 
gering life. The inflammatory action may be either super- 
ficial or interstitial ; when the latter, the disease may result 
in a chronic condition with permanent alteration of the 
tissue. 

Acute catarrhal inflammation of the larynx results from 
the same causes as produce similar affections of any mucous 
membrane, but laryngeal disturbances are less frequently 
found than of any other portion of the respiratory tract. 
Sedentary habits appear to favor the development of laryn- 
geal lesions. * Persons with lowered vitality are also the vic- 
tims of laryngeal diseases, as mucous membranes also par- 
take of the general subnormal condition. Castro-intestinal 
disturbances, through the same derangement of resisting 
power, will increase the liability. Cold and exposure, espe- 
cially wet or cold feet, or remaining inactive when the cloth- 
ing is damp, will predispose to this affection. Obstruction 
of nasal respiration, or vitiated air from any cause, will also 
prove a factor for the development of this condition. 

Extension of the inflammatory process to the trachea 
and bronchial tubes often occurs. Sex and age are not 



Acute Catarrhal Laryngitis. 435 

really factors, but the general condition of the patient, the 
habits of life and environment are of the utmost importance 
in producing the condition. Persons living an active, out- 
door life, provided their vocation will permit of not unneces- 
sarily exposing themselves to unfavorable conditions, are 
seldom affected with this disease. In some cases a laryngeal 
catarrh is simply an accompaniment of the eruptive fevers, 
influenza, hay fever, or occurs with an asthmatic tendency. 
The local application of drugs to the pharyngeal mucous 
membrane in pharyngitis has frequently produced laryngeal 
complications. The presence of foreign bodies around the 
larynx, or external pressure of any kind, may be factors. 

Pathology. — The pathology is identical with that of acute 
catarrhal inflammation of any portion of the upper respir- 
atory tract, excepting that on account of the deficiency of 
glandular elements in the larynx, the exudate is that of in- 
flammation, lacking the hypersecretion of the glands so 
freely distributed in the other portions of the tract. If the 
exciting cause is removed, there is a rapid return to the 
normal, but when the excitant is not removed, a chronic 
condition will follow, with permanent structural changes. 

Symptoms. — Often the first symptom noticed will be a 
desire to cough. This results from the lack of secretion. 
Change in the voice, coming on suddenly, and soon followed 
by soreness or a sensation of roughness and thickening in 
the throat and a constricted feeling, are complained of. 
Attempts to use the voice aggravate the symptoms, and in 
some instances the hoarseness will continue, throughout the 
attack, or the patient may be unable to speak above a whis- 
per. As a rule, the cough is shrill and metallic, and in the 
early stages dry and rasping. 

In children the respiration is more impeded than in 
adults, but as a rule is not specially distressing unless there 
is considerable edema, such as sometimes occurs in trau- 
matic cases. 



436 Nose, Throat and Ear. 

As the disease progresses and the second stage is reached 
the secretion will relieve the dryness, and the cough is less 
irritating and rasping. In children there is usually slightly 
increased temperature, and often some in adults. During 
the second or third stage in young people there may be 
suffocative attacks during sleep. These are probably the 
result of either accumulations of secretion, or of dried se- 
cretion within the larynx. The inflammation usually passes 
off rapidly, unless the exciting cause remains. 

Diagnosis. — Generally not difficult. In young persons, 
however, the possibility of the symptoms being those of 
some of the eruptive fevers, or diphtheria, should be re- 
membered. 

Prognosis. — Good. The majority of uncomplicated 
cases will recover in a few days with good hygienic treat- 
ment. 

Treatment. 1 — If there is increased temperature, and even 
when there is not, if the case is seen during the first or 
second stage, aconite in small doses every hour. Ipecac 
may be used in combination with the aconite, but the dose 
should not exceed y$ drop. After the second stage, collin- 
sonia will relieve the hoarseness and cough. When the se- 
cretion is tough, tenacious, and stringy, potassium bichro- 
mate will give the most relief ; the secretions soon become 
less tenacious, and the hoarseness and cough found with this 
form of secretion is rapidly relieved. 

It is important to remember that no more effort should 
be made to use the voice than is absolutely necessary. 

Acute Laryngitis in Constitutional Diseases. 

Erysipelas. — Laryngeal mvol cement may be primary 
or secondary. Not infrequently facial erysipelas of a sup- 
posedly idiopathic character is secondary to a faucial origin. 
The severity Of the attack varies as in any other location. 
The disease is often endemic or epidemic. 



Acute Laryngitis. 437 

Symptoms. — Often ushered in with a chill, then fever, 
and rapidly followed by vomiting, delirium, and general 
prostration. The local symptoms are pain, dyspnea, or 
odynophagia. During the early stages the larynx appears 
as in a simple acute laryngitis, but the disposition to exten- 
sion, systemic symptoms, and lymphatic involvement should 
make the diagnosis easy as a rule. 

Prognosis. — Guarded, as usually it is fatal. 

Treatment. — Same as in erysipelas of other regions. 

Measles. — A catarrhal inflammation of the upper res- 
piratory tract is characteristic of measles. This may pre- 
cede or accompany the cutaneous phenomena. Usually the 
laryngeal involvement is confined to the catarrhal type, but 
in some instances ulceration or gangrene may result from 
the mechanical irritation of excessive coughing. A pseudo- 
membranous form is sometimes seen. In a severe laryn- 
geal complication there will be a dry, hard, painful, and 
recurring cough ; loud, whistling respiration, and occasion- 
ally a spasmodic cough which is suffocative, and followed 
by expectoration of a dry, inspissated mucus. The larynx 
is deep red in color, and the vocal cords yellowish-red and 
somewhat injected. 

Prognosis. — Usually good, but a sudden edema may be 
an unpleasant complication. If a membranous or ulcerative 
condition arises, the prognosis is unfavorable. 

Treatment. — Locally the use of sprays that will relieve 
the pain, and internally the indicated remedy. 

ScareET Fever. — Usually the pharyngeal manifestations 
are only those of hyperemia, or a mild catarrhal inflamma- 
tion. In some cases, however, there may be severe laryn- 
geal complications, as edema, ulceration, or gangrene, which 
may cause a fatal termination. 

Smaee-pox. — In this disease there may be any grade of 
involvement, from a slight catarrhal stage to that of ulcer- 



438 Nose, Throat and Ear. 

ation, and possibly perforation. Asphyxia may occur in 
the malignant type. 

Typhoid Fever. — Occasionally a simple catarrhal in- 
flammation may occur. Ulceration is infrequent, but may 
be a complication. Usually these complications occur in the 
later stages of typhoid. 

Typhus Fever. — In this disease laryngeal complications 
are usually dangerous. The tissues are swollen, bright red, 
or of a dusky hue, and bathed with a tenacious mucus or 
pus. Infrequently a destructive process will denude the 
cartilages, leaving a blackish-gray surface. 




FiG. 92. Catarrhal ulcer of leit cord in an acute 
laryngitis resulting from typhoid fever. 

Influenza. — An acute inflammatory action is usually 
present in this disease. The mucous membrane is swollen, 
shining, and reddened. Sometimes grayish-white spots may 
be seen, resembling a superficial necrosis. Local or general 
edema may occur, and prompt action will be required. 
Paralysis, spasm, or a chronic inflammatory action may 
follow in these cases. 

Miasmatic Epiglottitis. — An acute inflammatory ac- 
tion, implicating the epiglottis, may occur. Edema is the 
marked condition, and may require a tracheotomy. Croupal 
symptoms often present in so-called malarial poisoning, but 
the diagnosis should be easily made by the general mani- 
festations. 



Acute Laryngitis in Children. 439 

Treat ii lent. — Puncture or scarification of the epiglottis. 
Apis or apocynum internally, and the proper treatment for 
the periodicity. 

Rheumatism. — That rheumatism may cause an acute 
affection of the larynx is unquestioned. The action is prob- 
ably that of a rheumatic arthritis. There is pain on speak- 
ing, the articulations are swollen and tender, and the vocal 
cords may be immobile, swollen, and reddened. 

Treatment. — Sedative local measures, and internally 
rhus, bryonia, cimicifuga, salicylic acid, or the salicylates, 
colchicum, and rhamnus Californica. 

Acute Laryngitis in Children. 

Synonyms. — Spasmodic croup ; False croup. 

The etiology and pathology of an acute catarrhal inflam- 
mation in children are the same as in adults ; but as the 
laryngeal structures are smaller in the former, the mucous 
tissues more relaxed, and a more rapid engorgement occurs, 
it is a more serious condition, and the symptoms are more 
pronounced. The membrane affected may be above or be- 
low the glottis, or both may be affected. The terms supra- 
glottic, subglottic, and acute laryngitis are used to desig- 
nate the tissue implicated. The age most often affected is 
between two and five, but it may occur earlier, and as late 
as fifteen. Any slight catarrhal inflammation of the upper 
respiratory tract may be a factor, or an inflammatory state 
of the faucial, lingual, or pharyngeal tonsil. Exposure to 
cold, alimentary disturbance, or some systemic condition 
may cause or be associated with the condition. 

Symptoms. — Hoarseness or even aphonia, sometimes 
cough, febrile symptoms, and dyspnea, especially in the sub- 
glottic form. When supraglottic, dyspnea is slight, as is the 
spasm of the glottis. The tendency to extension must be 
remembered, particularly if the contiguous structures are 
involved. The fact that supraglottic inflammation may be 



44-0 Nose, Throat and Ear. 

an early symptom of diphtheria or scarlet fever, should be 
remembered. It is usually difficult to make a laryngoscopic 
examination in children, and not infrequently impossible, 
but patience and careful manipulation will often prove suc- 
cessful. 

Treatment. — Usually, the less local treatment, the better. 
Swabbing the larynx is brutal. Internally, aconite and ipe- 
cac, in small doses frequently repeated, are all that is re- 
quired. Emesis is seldom if ever necessary in these cases. 

Prophylaxis. — Much can be accomplished by using cold 
sponge baths to the neck, chest, and back, followed by brisk 
rubbing with a coarse towel. This should be sufficient to 
redden the skin. Free ventilation of the sleeping apartments 
at all seasons should be insisted upon. The wearing of 
chest-protectors, mufflers, etc., should be condemned, as they 
render the patient more susceptible to colds. Warm cloth- 
ing, but not an excessive amount, should be worn. These 
precautions will diminish catarrhal diseases in children and 
aaults. 

Laryngismus Stridulus. 

Synonyms. — Asthma rachiticum ; Cerebral croup ; Child 
crowing ; False croup ; Miller's asthma ; Laryngeal spasm ; 
Spasmodic croup ; Spasmodic laryngitis ; Spasm of the 
larynx ; Spasm of the glottis ; Spasm of the abductors of 
the vocal cords ; Spasmus glottidis ; Thymic asthma. 

In this condition there is laryngeal spasm and stridor, 
and it is an unpleasant symptom which may accompany any 
laryngeal or tracheal disease. It may be present in any form 
of croup, in whooping-cough, alimentary wrongs, dentition, 
rachitis or neurotic children, or caused by mechanical irri- 
tation of the faiices or nasopharynx. In adults it may be a 
reflex from the generative organs ; pressure resulting from 
carious cervical vertebrae or an enlarged thymus gland 
(thymic asthma) ;' abscesses, either acute or chronic; or 
pressure on any portion of the pneumogastric or spinal ac- 



Spasm of the Larynx in Children. 441 

cessory nerve may be a cause. A bilateral or unilateral 
paralysis of the posterior crico-arytenoid muscle may be 
present. Cerebral irritation or lingual lesions may be a 
cause. In fact, it is to be considered as a local manifestation 
of some constitutional or local disturbance, a symptom and 
not a disease. 

Treatment. — This must be directed to the immediate 
cause, but in some cases radical measures are required. 
Tracheotomy may be necessary. Traction on the tongue, 
holding it firmly and making rhythmical traction sixteen or 
eighteen times a minute, may afford relief. Firm pressure 
with traction at the angle of the jaw will also often relieve 
the condition. Cold water applied to the face or neck, or 
hot water at the back of the neck, may give relief. 

Spasm of the Larynx in Children. 

Synonym. — Spasm of the glottis in children. 

A subnormal child under unfavorable environment, or 
through any agency which will produce irritation of the 
nervous system, or the entrance of foreign bodies in the 
esophagus or larynx, may be subject to. laryngeal spasm. 

Symptoms. — Children under two years of age are most 
frequently affected. The attack is usually sudden, respira- 
tion is labored, and sometimes for a number of seconds is 
impossible. If the attack comes on during sleep, the facial 
expression is that of terror. The patient may become cy- 
anotic, the neck turgid, convergent strabismus occur, and' 
convulsive movements of the extremities, or even a general 
convulsive attack ; with relaxation of the laryngeal spasm 
there is a subsidence of the alarming symptoms, and the 
child falls back exhausted. A rapid recurrence of the symp- 
toms may follow, or there may be an interval of months 
between the attacks. The nutrition is still more impaired 
through the disturbance of the nervous system. 
. Diagnosis. — The sudden attack is usually conclusive. 



442 Nose, Throat and Bar. 

In morbid growths causing dyspnea, there is usually a pro- 
gressive action. Intralaryngeal tumors generally cause 
hoarseness or loss of voice. Edema, general infectious 
diseases, or laryngitis, as a rule, show fever or some char- 
acteristic symptoms. Very seldom is bilateral abductor pa- 
ralysis found in infancy. 

Prognosis. — The frequency of the attacks and the gen- 
eral condition of the patient will govern the prognosis. 

Treatment. — During the attack the child should be in a 
semi-recumbent position, the clothing loosened, and plenty 
of fresh air admitted to the room. The administration of 
lobelia or gelsemium, dropping the concentrated preparation 
on the tongue, will usually give relief. In some cases, in- 
tubation or tracheotomy may be necessary. Rhythmical 
traction of the tongue may afford relief, but the use of 
lobelia will usually relax and give relief quicker than any 
other measure. During the intervals of recurrence, the 
treatment should be directed to the causative factor. 

Spasm of the Larynx in Adults. 

Synonym. — Spasm of the glottis in adults. 

Etiology. — Abnormal states of the nervous system are 
predisposing causes. A reflex from some lesion of the res- 
piratory tract is often a factor, as in some instances a sys- 
temic disease may be productive of laryngeal manifestations. 
Hysteria may also be a cause. 

Symptoms. — The dyspnea usually occurs at night, and 
varies both in intensity and duration. A struggle for breath, 
a limited number of crowing, noisy respirations and cy- 
anosis. The spasm usually lasts not to exceed twenty sec- 
onds, when it gradually subsides. The attacks are more 
irregular in recurrence than in children. If they occur dur- 
ing the daytime, they are usually the result of some central 
nervous lesion, the result of pressure, or a systemic disease. 

Diagnosis. — To determine the actual cause is the greatest 



- Spasmodic Laryngitis. 443 

difficulty. The diagnosis must be made by exclusion. In 
bilateral abductor paralysis the laryngoscopic examination 
will show the lack of abduction. 

Prognosis. — Unless the result of systemic disease, the 
prognosis is usually favorable. 

Treatment. — Correction of any abnormalities of the 
upper air passages. If due to some systemic disease, this 
should be looked after. For the relief of the attacks, the 
treatment is essentially the same as in spasm of the larynx 
in children. 

Spasmodic Laryngitis. 

Synonyms. — Catarrhal croup ; Catarrhal laryngitis ; Lar- 
yngitis stridulosa ; Mucous croup ; False croup ; Pseudo- 
croup ; Stridulous angina ; Stridulous laryngitis ; Spasm of 
the larynx ; Spasmodic croup ; Spurious croup. 

There is always an inflammation of the laryngeal and 
tracheal mucous membrane, with an associated spasmodic 
contraction of the laryngeal muscles. This causes cough, 
difficult respiration, stridor, and sometimes dyspnea. The 
spasm is not dependent upon the amount of inflammatory 
action. When supraglottic there is often spasm, while if 
subglottic a true or membranous croup is the condition, but 
both forms may exist. A neurosis may cause laryngeal 
stridulus without inflammatory action. 

Etiology. — An inherited tendency is often present, and 
any state of the system causing a lowered vitality predis- 
poses to this condition. Colds are the most frequent excit- 
ing factor. It is not infrequently found as a precursor of 
children's diseases. 

Symptoms. — The attacks may occur at any age, from 
a few months to ten or twelve years. Usually there is some 
cough and symptoms of coryza preceding the attack, but 
often there are no premonitory symptoms. The attack is 
most frequently between ten and two o'clock at night. 
After a natural sleep varying in duration, the child awakes 



444 Nose, Throat and Ear. 

with a loud, rasping, wheezing, asthmatic cough, the respi- 
ration is very labored, and on inspiration there is a peculiar 
whistling sound. The face is markedly flushed, and there 
is an anxious and terrified expression. The child will usu- 
ally cling to the attendant as if in terror. The pulse, on 
account of increased vascular tension, the result of the im- 
paired respiration, will be rapid and hard. The duration 
of the attack varies from half an hour to two or three hours. 
Infrequently there may be two or more attacks the same 
night, but usually they are repeated on successive nights. 
As a result of the coughing and forced respiration, there 
is usually a decided inflammatory action following the 
paroxysm. A hoarse, croupy cough, with an excessive 
catarrhal secretion, often lasts for several days, and if a 
decided cold has been contracted, a catarrhal pneumonia 
may result. 

Diagnosis. — Not infrequently this is mistaken for pseudo- 
membranous croup, but in the latter the disease is insidious, 
the cough which is present increasing gradually, and does 
not abate during the day. In spasmodic laryngitis the 
paroxysm is sudden and rapidly reaches the climax, and 
invariably occurs at night. The cough is loud, wheezy, and 
dry, and change in the voice is simply the result of impaired 
respiration, and is sudden. There is slight or no inflam- 
matory action of the faucial structures. In true croup, on 
account of the membrane, the cough is harsh and rough, 
and increases in severity. The voice is changed, owing to 
the presence of the membrane, but the change is gradual. 

Prognosis. — Usually favorable, as rational treatment will 
generally effect a cure. Fatal results may follow in some 
cases, so the general condition of the patient must be con- 
sidered. 

Treatment. — The relief of the spasmodic action of the 
laryngeal muscles, and alleviation of laryngeal inflamma- 
tion are important. Placing the child in a bath I consider 
barbarous. The treatment I have found most beneficial 



Acute Epiglottitis. 445 

was employed by my father in over forty-five years of 
active practice, a large proportion of his work being among 
children. The child should be allowed to remain in its crib 
or bed. No extra clothing should be placed over it. Plenty 
of fresh air should be admitted to the room, but the temper- 
ature should not be allowed to drop below 6o° Fah. Emesis 
is seldom, if ever, required. The following is given: 
1^ Aconite, gtt. iij-v; ipecac, gtt. viij-xv; aqua, qs. 
§jv. Mix. Teaspoonful every fifteen minutes for an 
hour, then every half -hour or hour. In the majority of 
cases the child will be sleeping quietly before an hour has 
passed. The medicine can be continued during the waking 
hours, giving it every two hours, and it will relieve the irri- 
tation of the mucous tissues, preventing a recurrence of the 
attack in many cases. The production of emesis simply 
takes the strength of the little patient, and renders it more 
susceptible to subsequent attacks, and often with a fatal 
termination. During the intervals of the paroxysms, or 
following a single attack, such hygienic and medicinal meas- 
ures should be instituted as will lessen the susceptibility of 
the patient to climatic changes. 

Acute Epiglottitis. 

This is not really a distinct condition, as it is always 
associated with an inflammation of contiguous structures, 
but the epiglottis appears to be the most affected. It is often 
found accompanying lesions of the lingual tonsil. 

Symptoms. — There is a sensation as of a foreign body in 
the throat, and a disposition to gag or vomit, some diffi- 
culty in swallowing, but practically no pain. Edema is 
usually present, and there is profuse secretion, especially 
after eating. Tenderness on pressure is seldom present, 
but occasionally there may be slight tenderness over the 
hyoid bone. 

Treatment. — This is the same as for acute laryngitis. 



446 Nose, Throat and Ear. 

Traumatic Laryngitis. 

This form of inflammation is similar to that of an acute 
pharyngitis, but the severity depends upon the direct cause. 
The inflammatory process is severe, and the mucous tissues 
of the larynx and contiguous structures are involved. If 
the result of direct injuries or foreign bodies, the inflam- 
mation may not extend beyond the larynx. When the result 
of inhalation of vapors, or corrosive substances, the tissues 
of the fauces, tongue, and pharynx are implicated. Gan- 
grene often follows from corrosive poisons, burns, or scalds. 
Edema is usually present. If the laryngeal trouble is due 
to a foreign body, tracheotomy may be required. If the 
condition is the result of scalds or corrosive substances, 
emollient preparations are required. The chloretone in- 
halant will be found useful. Puncture of the tissue may be 
necessary, but usually the prompt use of apis or apocynum 
will be all that is required. Tracheotomy may be necessary 
in some cases. 

Suppurative Laryngitis. 

Synonyms. — Phlegmonous laryngitis ; Purulent laryn- 
gitis ; Suppuration of the larynx. 

These terms are really misnomers, as suppuration of the 
laryngeal mucous membrane is secondary to bony, carti- 
laginous, or submucosa infection from the laryngeal struc- 
ture. A chondritis or perichondritis, usually due to syphilis 
or typhoidal conditions, is the usual cause. Edema of the 
larynx is always a complication which may result in suppu- 
ration. The superior portion of the larynx is most often 
affected, but by extension the cords and inferior portion 
may be involved. The pathological changes are those of 
abscess formation elsewhere. 

Symptoms. — There may be external swelling, and there 
is an external localized point of tenderness. While the pain 



Rheumatic Laryngitis. - 447 

is continuous, it is not severe. Pressure increases the pain, 
and deglutition is difficult. The voice and respiration are 
irregularly affected. There are cyanotic periods, and a con- 
stant disposition to clear the throat. Choking paroxysms 
are frequent, and are usually relieved after a violent cough- 
ing spell. The inflammation of the tissue is so severe that 
inspection of the larynx is practically impossible. 

Diagnosis. — The symptoms described, and the gradual 
progress of the disease will differentiate from diphtheria, 
membranous or spasmodic croup. 

Prognosis. — Unfavorable. Suffocation or a constitu- 
tional infection usually results. 

Treatment. — Internally, the use of calcium sulphide, 
silicea, gold and sodium chloride, apis or apocynum. Scari- 
fication may be required, and often tracheotomy. 

Rheumatic Laryngitis. 

Snyonyms. — Gouty throat ; Gouty sore throat ; Laryngeal 
rheumatism. 

This differs from an acute laryngitis in being a local 
manifestation of a systemic wrong. The pain is intense, 
and there is in addition a bruised sensation. It may pre- 
cede, accompany, or follow a general rheumatic condition, 
or it may be the only manifestation of the disease. Deglu- 
tition or external pressure may increase the pain, or the re- 
verse may be true. Slight laryngeal hemorrhage may occur 
in severe cases. The pharyngeal tissues and tonsils are often 
involved. The voice is usually changed, and aphonia may 
be present. Hebetude may be marked, as well as a general 
debilitated condition. The neck and throat muscles usually 
feel sore and bruised. If the result of a true gouty con- 
dition, there may be deposits at the crico-arytenoid articu- 
lations. 

Treatment. — The same as in rheumatic pharyngitis. 



448 Nose, Throat and Ear. 

Edematous Laryngitis. 

Synonyms. — Acute cellulitis of the larynx ; Edema glot- 
tidis ; Edema of the glottis ; Phlegmonous laryngitis ; Puru- 
lent suppurative laryngitis. 

In this there is a watery infiltration into the submucosa, 
resulting from sudden hyperemia, or hyperemia and con- 
gestion from inflammation, or in cyanotic conditions (angio- 
neurotic). The edematous process is virtually always the 
same, although the exciting cause varies. When infectious, 
the process is usually rapid. 

Etiology. — It may follow injuries, inhalation of steam 
or irritating vapors, or the use of escharotics. Edema may 
result from inflammation of surrounding or adjacent tis- 
sues ; enlarged or suppurating lymphatics of the neck caus- 
ing pressure ; injuries or foreign bodies at the base of the 
tongue ; tumors of adjoining structures which impede venous 
return ; foreign bodies lodged in the esophagus behind the 
larynx or trachea, or a chondritis or perichondritis. Edema 
is often associated with specific inflammations, and may be 
a complication of typhoid fever. Edema may be primary, 
but usually is secondary. A chronic type may result from 
cardiac lesions. In fibroid changes of the kidneys, liver, 
or lungs, causing interference with the vascular system, es- 
pecially the venous flow, a cyanotic condition of the mucous 
membrane is produced similar to that in cardiac disease. In 
specific inflammation, the result of local ulceration, with 
Allowing" fibroid tissue formation and cicatrization, the ve- 
nous system may be implicated sufficiently to cause local 
edema. Major surgical operations about the throat or lower 
jaw may also be a cause, through excessive cicatrization. 
Infectious conditions of the mucous surface, as in diph- 
theria, scarlet fever, and streptococcal infection, may cause 
an acute edema. 

Pathology. — The vascular arrangement of the larynx, 



Edematous Laryngitis. 449 

and lack of support of the mucous membrane vessels, allows 
rapid congestion and exudation into the perivascular struc- 
ture. This serum distends the intercellular spaces and 
lymph channels, and some is taken up by the connective 
tissue or epithelium. Hydropic degeneration results if 
prompt relief is not obtained in the chronic type; in the 
acute type this result seldom occurs. The edema may be 
most marked in the ventricular bands, the epiglottis, or the 
aryepiglottic folds. The entire larynx may be affected, the 
trachea and the muscles of the neck may be involved. This 
is most marked when due to the inhalation of irritating- 
vapors, the use of escharotics, or of foreign bodies. 

Symptoms. — In the acute type the edema is sudden, and 
if associated with inflammation of contiguous structures 
a chill may be a precursor. The voice is rapidly affected, 
and stridulous respiration is marked. Dyspnea is an early 
symptom, and rapidly becomes more labored. The face is 
flushed, and the entire circulatory system gives evidence t>f 
impaired respiratory function. An apprehensive and rest- 
less state is noted. The symptoms rapidly increase, and in 
some cases death results, unless prompt surgical relief is 
rendered. Usually the course of the attack is not so serious. 
Pain is felt on swallowing, a sensation as of a foreign body, 
a disposition to clear the throat, with but little expectoration, 
and a wheezy cough. The patient is inclined to keep in an 
upright position, leaning a little forward. 

Examination will reveal the epiglottis swollen, so much 
so that a laryngeal image can not be obtained. A rapid 
digital examination, as well as the symptoms of laryngeal 
obstruction, will confirm the diagnosis. Usually the entire 
laryngeal tissue is affected, as well as the surrounding tis- 
sues. In the chronic form the symptoms are less severe 
and slower in developing, and the respiration not so mark- 
edly impeded. This state may continue for a number of 
weeks without any serious complications. The cyanotic 
29 



450 Nose, Throat and Ear. 

condition is often relieved by the collateral circulation. 
When the edema results from cicatrization or local causes, 
as tumors, the symtoms may require tracheotomy. 

Diagnosis. — Acute edema is determined by examination 
and the subjective symptoms. In chronic edema by the his- 
tory and laryngo-scopic examination. 

Prognosis. — Usually good in the acute type, if promptly 
treated. When much of the structure is involved, and it 
extends too low to be relieved by tracheotomy, the prognosis 
is unfavorable. 

Treatment. — For the relief of the edema, apis, or apocy- 
num will usually give prompt relief. Scarification or punc- 
ture may be required as a preliminary measure. If the 
edema is dependent upon cardiac, hepatic, or renal disease, 
free catharsis with salines or elaterium should be continued 
until the condition is relieved. A careful examination should 
be made to determine the exciting cause, and the treatment 
directed to this. In edema associated with syphilis, the ad- 
ministration of potassium iodide frequently increases the 
condition, and should be discontinued. 

Chronic Edema of the Larynx. 

This may result from an acute edema, but usually is a 
local manifestation of some constitutional disease, as syph- 
ilis, tuberculosis, or malignant growths. The morbid 
changes are those of hydropic degeneration and pressure 
atrophy. 

Prognosis. — Very unfavorable. 

Treatment. — Depends upon the cause. 

Membranous Laryngitis. 

Synonyms. — Croupous laryngitis ; Cynanche t.rachealis ; 
Diphtheritic croup ; Fibrinous croup ; Fibrinous laryngitis ; 
Idiopathic membranous croup; Laryngeal diphtheria; Lar- 



Membranous Laryngitis. 451 

yngotracheitis ; Membranous croup ; Pseudo-membranous 
croup ; Pseudo-membranous laryngitis ; True croup. 

Membranous laryngitis is divided into three varieties 
corresponding to membranous inflammation of the nose and 
pharynx. These are croupous, diphtheritic, and fibrino- 
plastic. The croupous and fibrinoplastic will be considered, 
as the diphtheritic properly belongs under diphtheria. 

Etiology. — Membranous inflammation of the mucous 
membrane depends upon the systemic condition and some 
irritant of the mucous membrane. It may follow the em- 
ployment, accidental or otherwise, of corrosive chemicals, 
burns, scalds, inhalation of irritating vapors, thermo-cautery, 
wounds, and also by the action of some pathogenic bacteria. 
The Klebs-Loffier bacillus, in its true virulent form, is not 
an etiological factor. Membranous inflammation may occur 
at any season, and is most frequently seen in children be- 
tween the ages of one year and six years. It is compara- 
tively infrequent later in life. Boys are most often affected. 
It is often found in children as a complication in the exan- 
themata, or it may be secondary to membranous inflamma- 
tion of the pharynx or tonsils. As a rule, membranous in- 
flammation of the larynx is diphtheritic, but it is impossible 
in many cases to make a positive diagnosis excepting by 
a close watching of the case. There is no doubt that many 
cases of the fibrinous variety of membranous inflammation 
are neither contagious nor infectious, although often there 
is little clinical difference between this and true diphtheria. 
The morbid differences are also often very similar, except- 
ing that in the non-diphtheritic form the false membrane is 
on the surface of the mucous membrane, and on removal 
neither necrotic changes nor ulceration are found. In diph- 
theritic inflammation, ulceration, perforating the basement 
membrane is present, the exudate and acute inflammatory 
action being confined mostly to the laryngeal structure. 
Systemic infection is more pronounced in diphtheritic in- 



452 Nosk, Throat and Ear. 

flammation, as well as the clinical symptoms. While isola- 
tion of a case is advisable, a too hasty diagnosis of diph- 
theria should not be made. In the latter disease the symp- 
toms increase in intensity, but in the non-diphtheritic type 
there will be an amelioration in twenty-four or forty-eight 
hours, and a cure in three or four days as a rtile. Remem- 
ber that membranous laryngitis is not always diphtheria. 

Pathology. — The changes are those of an acute inflam- 
matory process. 

Symptoms. — The most pronounced and alarming symp- 
toms are the peculiar brazen cough, usually stridulous res- 
piraton, hoarseness of the voice, and often dyspnea. Fever 
usually increases gradually. Prior to the attack there is 
often some cough or catarrhal inflammation. This may con- 
tinue for three or four days, when the symptoms may dis- 
appear. A slight membfane may form without any marked 
systemic symptoms, or the symptoms may rapidly grow 
worse, the cough becoming harsh and ringing, the voice 
rapidly changing, and the respiration labored. High fever 
and general depression appear later. Remissions of the con- 
dition will be marked. The eliminative functions are de- 
ranged, there being scanty, high-colored urine, bowels con- 
stipated, skin dry, and the patient very thirsty. Restless- 
ness is marked, the patient keeping the head well back, the 
respiration is difficult, and the croupal sound more or less 
constant. Shreds or masses of membrane are often coughed 
up or vomited. Deglutition is seldom affected. Occasion- 
ally the cough entirely disappears. Dyspnea may be con- 
stant, instead of paroxysmal. The skin is livid and par- 
tially anesthetic, and the extremities become cold. Death 
is pretty sure to follow unless prompt relief is obtained. 
Bronchitis or pneumonia may be a complication if the attack 
continues for several days. When a laryngoscopic view can 
be obtained, it will reveal the membrane, immobility of the 
vocal cords, and apparently a binding together "of the aryte- 



Hemorrhagic Laryngitis. 453 

noid cartilages and the interarytenoid space by the false 
membrane. 

Diagnosis. — The disease may be mistaken for spasmodic 
laryngitis, acute laryngitis, edema of the larynx, diphtheria, 
retrolaryngeal or retropharyngeal abscess, tonsillitis, whoop- 
ing cough, capillary bronchitis, or foreign bodies in the 
larynx or throat. 

Prognosis. — In severe cases always doubtful. The mor- 
tality is always high. Extension of the disease to the trachea 
or bronchial tubes is a serious complication. 

Treatment. — The salicylic acid wash used in an atomizer 
is often beneficial-; The air of the room should be made 
moist by the jise of steam. Emesis is usually to be avoided, 
as the strength of the child should be conserved. Internally 
aconite, gelsemium, ipecac, lobelia in small doses, jaborandi, 
Phytolacca, collinsonia, potassium bichromate, apis, apocy- 
num. For sustaining the patient's strength, whisky or 
brandy. 

Surgical Measures. — If remedies fail to relieve the con- 
dition, and there is a steady increase of the stenosis and 
constant dyspnea, intubation or tracheotomy should be per- 
formed, preferably the former, as more cures result than in 
tracheotomy. 

Hemorrhagic Laryngitis. 

Synonym. — Hemorrhagic inflammation of the larynx. 

This is a distinct condition from laryngeal hemorrhage. 
The latter may result from syphilitic or tubercular ulcer- 
ation, from malignant disease or from a traumatism. It 
may be the result of a rapid acute inflammation, or of a 
lesion of the walls of the arteries. In these the hemorrhage 
is secondary. Hemorrhagic laryngitis is infrequent. 

Pathology. — If the hemorrhage is in the tissue, and is 
from a ruptured vessel, a small hemorrhagic infarction 
occurs. When this is in the submucosa, absorption may 
occur without any material change resulting. If the area is 



454 Nose, Throat and Ear. 

sufficient to interfere with the blood supply and produce 
local non-infected necrosis, provided the surrounding in- 
flammatory area has good nutrition, the necrotic space will 
be filled with connective-tissue cells or granulation tissue, 
leaving some cicatricial changes. 

Symptoms. — Inspection will determine whether the site 
of the hemorrhage is above the larynx or not. If it is from 
below the vocal cords, the blood will be mixed with mucus. 
If from the larynx, rales in the lungs will be absent, and the 
mucus and blood are not thoroughly mixed. The laryngo- 
scopy image may reveal the hemorrhagic site. 

Prognosis. — Seldom fatal, and not often profuse. In 
advanced cases of pulmonary tuberculosis, laryngeal hemor- 
rhage may occur. In such cases the prognosis will be gov- 
erned by the condition of the patient. 

Treatment. — Practically as in hemorrhagic conditions 
of the mucous membranes elsewhere. If hematoma is 
formed, it should be opened and the clot removed. The use 
of intralaryngeal applications usually do more harm than 
good. 

Chondritis and Perichondritis. 

The two conditions are so closely allied that they will be 
grouped under one heading. 

Etiology. — A traumatism of any kind, either direct or 
indirect, may cause an inflammation of the cartilage or peri- 
chondrium. Infected emboli or infective material absorbed 
by or passing through the mucous membrane may also cause 
this condition. Foreign bodies lodged in the esophagus 
back of the larynx may also be factors. Gout or rheumatism 
may be an etiological factor. Specific inflammations as syph- 
ilis, tuberculosis, actinomycosis, and glanders, may have an 
incidental relation to the affection. The disease may result 
either by direct involvement or by pyemic metastasis in diph- 
theria, smallpox, and typhoid fever. Benign or malignant 
tumors of the larynx or parts contiguous may be a factor. 



Chondritis and Perichondritis. 455 

Pressure of the plates of the cricoid against the vertebrae 
in the aged, or in persons compelled to lie in bed for a con- 
siderable period, has been credited as a cause of perichon- 
dritis. Exposure to cold or damp, chilling of the body, 
overuse of the voice when there is an inflammatory state of 
the larynx, may produce a painful inflammatory action in 
part or all of the laryngeal cartilages or their perichondrium. 

Pathology. — Syphilis. — The morbid changes here are 
similar to those in other cartilages from this disease. 

Tuberculosis. — The laryngeal lesion may be primary or 
secondary. Considerable edema is usually present in peri- 
chondrial infection, impeding laryngeal movement and 
markedly changing the voice. Ulceration is slight in the 
early stage, but later the edema diminishes, and a gray ulcer- 
ation, usually beginning behind, slowly advances toward the 
front. Some edema nearly always remains. The secretions 
are adherent and tenacious. In the later stages, necrotic 
or gangrenous conditions of the cartilages may occur. 
Fungus formations may be seen growing from the edges of 
the ulcerated surface. These are termed tuberculous granu- 
lomata or papillomata. 

Typhoid Fever. — First there is hyperemia and conges- 
tion, soon followed by an inflammatory edema, with exuda- 
tion into the surrounding or contiguous soft tissue. The 
edematous stage and the ulcerative stage, which has pro- 
gressed to necrosis of the cartilages, differ in degree only, 
but not in kind. The arterial supply of the laryngeal carti- 
lages is poor at all times, so these are quite susceptible to 
necrotic changes. During an attack of typhoid fever there 
is a general subnormal nutrition, and the circulation to this 
location, depending as it does largely upon the surrounding 
tissue, is very much diminished. Necrosis of the tissue rap- 
idly follows, which may slough out in small pieces, or alto- 
gether. The probability is that in the majority of cases of 
chondritis or perichondritis resulting from typhoid fever, 



456 Hose, Throat and Ear. 

the infection and inflammatory process simulate those of 
abscess formation and follow the line of least resistance, 
opening on the mucous membrane as an ulcer. The typhoid 
bacillus is generally found in the necrosed material. Ulcer- 
ation is usually located posteriorly, and the cartilaginous 
lesion is on the side and toward the posterior portion of the 
larynx. When the perichondrium remains, and only a por- 
tion of the cartilage is destroyed, new cartilage may be 
formed. 

Traumatism ; Rheumatism. — In chondritis or peri- 
chondritis, the result of either of these causes, there may be 
absorption and resolution of the exudation and swelling. 
Usually prompt treatment and complete remoyal of the af- 
fected tissues is necessary on account of the severity of the 
symptoms. The condition usually commences as a peri- 
chondritis. 

Order of Implication.— The cricoid cartilage is generally 
most affected, and also the most frequently. The inner sur- 
face is usually markedly tumefied. The arytenoid is next, 
generally unilateral, and affects both the air and esophageal 
tracts. Necrosis usually occurs earlier in this than in the 
cricoid. The thyroid cartilage may have one or both sur- 
faces affected, and one or both wings, but the rule is one, 
and on the inner side. The blood supply to this cartilage 
is fairly good, so extensive necrosis is less liable to occur. 
The epiglottis is not often primarily involved, but may be 
secondarily. The tracheal rings sometimes are affected. 
Occasionally in any of these, organization may follow after 
necrosis, resulting in a collapse of the necrotic portion, and 
finally scar-tissue. 

Symptoms. — These are almost the same as in chondritis 
and perichondritis, and a differential diagnosis is not im- 
portant, the treatment being similar in each. 

Syphilis and Tuberculosis. — In chondritis or peri- 
chondritis the symptoms resulting from either of these dis- 



Chondritis and Perichondritis. 



457 



eases are very similar. They are not unlike those found in 
chronic laryngitis, but in the tubercular form there is more 
pain. An increase of temperature is usually present in 
either syphilitic or tubercular forms. In the latter, edema 
may be so pronounced as to require tracheotomy. The act 
of swallowing is also painful, as the posterior' portion of 
the larynx is usually affected. Complete or partial aphonia, 
due to destruction of the laryngeal cartilages, may occur 
later in the disease. If spontaneous rupture occurs, it may 
be into the larynx or pharynx. The epiglottis may be af- 
fected, and is an unpleasant complication. In syphilis there 




Fig. 93. Syphilitic perichondritis of the right wing of 
the thyroid cartilage, causing a swelling be- 
neath the right ventricular band. 



may be the characteristic odor of the secretions. Pain on 
swallowing is increased in both forms. 

Typhoid Fever. — When chondritis or perichondritis are 
present as a complication of typhoid fever, it may not be 
discovered for several days. Hoarseness and difficulty in 
swallowing are common complications. They may continue 
for some time, when suddenly, from a slight cold, exposure, 
or without any known factor, deglutition becomes more 
painful and there is an increase of hoarseness. Usually 
there will follow in a few hours difficult breathing, and often 
suffocative paroxysms. Laryngeal stenosis results, with 
stridor, inspiratory depressions of the neck and chest-walls, 
and the respiration becomes labored and noisy. Dyspnea 



458 Nose, Throat and Ear. 

increases, and swallowing is almost impossible. There is 
not much increase of expectoration. The suffocative attacks 
become more frequent and alarming. The face is livid, and 
the expression that of anguish. Tracheotomy may be nec- 
essary. 

In some cases a "discharge of pus and necrosed cartilage 
may afford relief. Recurrence is not infrequent, or a perma- 
nent fistula may result. The temperature is not often as 
high as in an acute abscess. The process may last for days 
or weeks. In the early stage, when the disease is confined 
to the perichondrium, ftie symptoms are most severe. In 
the acute stage the action is rapid. Emphysema of the tis- 
sues of the neck may result from a perforating ulcer in the 
posterior wall of the larynx. Occasionally suppuration may 
extend downward into the mediastina. Fortunately neither 
of these complications is frequent, but occurs oftener in 
adults than in children. Necrosis of the cartilage is fre- 
quent and also dangerous, increasing the mortality to about 
95 per cent of the cases so affected. 

The laryngoscopic examination will show the posterior 
plate of the cricoid cartilage involved, as a rule. Wherever 
located, there will be an irregular, nodular and unilateral, 
sharply-defined swelling. Ulcers may occasionally be seen 
on the posterior wall of the larynx or the vocal cords. Con- 
gestion and swelling of all the surrounding tissues may be 
present. Paralysis of the muscles may occur, more fre- 
quently in males. 

Rheumatism, Traumatism, Exposure: to Colds, Etc. 
— Characteristic symptoms are usually absent in the earlier 
stages, although some hoarseness and localized pain may be 
present. The latter is more marked on movement or ex- 
ternal pressure. Deglutition or use of the voice may cause 
discomfort or pain. Eventually hoarseness and sometimes 
cough may develop. Difficult deglutition, and later difficult 
breathing, with sometimes paroxysmal, suffocative attacks. 



Chondritis and Perichondritis. 459 

and eventually stenosis may occur. Evacuation of the ab- 
scess by any means will relieve the symptoms. 

Cricoid Cartilage. — When this cartilage is the site of 
the disease, the posterior surface is most liable to be affected, 
as a result of irritation. The inflammatory process generally 
extends from the upper articular surface toward the aryte- 
noid cartilage. Both inspiratory and expiratory dyspnea 
results. Aphonia and dysphagia always occur, which may 
be temporary or permanent. Cough is usually present. 

Arytenoid Cartilage. — Perichondritis of these struc- 
tures is frequent. Swelling over the cuneiform cartilage, 
and an abnormal sluggish movement of the vocal cords will 
present. When the crico-arytenoid articulation is affected, 
ankylosis or necrosis may occur, which may produce a per- 
manent change, or even loss of the voice. 

Thyroid Cartilage. — When the site is external, the 
swelling can be felt and seen. The pain is localized, whether 
on the inner or outer surface of the larynx. A bulging in- 
ward at the anterior angle between the vocal cords may 
occur. Change of voice will be noticed, and interference 
with respiration and deglutition, depending upon the sever- 
ity of the attack. When the entire cartilage is affected, 
death usually follows. 

Perichondritis of the small cartilages can not be deter- 
mined clinically. Ossification of the laryngeal cartilages 
usually results in the aged. 

Fibrous degeneration, while possible, has never been au- 
thoritatively reported. 

Diagnosis. — Syphilitic Perichondritis. — The history, 
when obtainable, and a careful search for previous syph- 
ilitic lesions. Swelling is usually more pronounced in syph- 
ilitic than in tubercular infection. A disposition to heal is 
also more marked in the former than in the latter, or in a 
carcinomatous condition. The secretions are fairly profuse, 
and in syphilis have a decided odor. 



460 Nose, Throat and Bar. 

Tuberculosis. — In the early stages the mucous mem- 
brane is pallid, and circumscribed, nodular, tumefied areas 
are seen, most frequently about the supra-arytenoid ex- 
tremity of the aryepiglottic fold, and usually more promi- 
nent posteriorly. They are not always on the same side as 
the affected lung. The family history is important, and a 
bacteriological examination is often an aid. The edema is 
usually more chronic than in syphilis. When ulceration oc- 
curs, it presents a more worm-eaten appearance than in 
syphilis, the surface being covered with * a greenish, tena- 
cious pus and surrounded with papillomatous proliferation. 
The ulcertion usually extends from below upwards, while in 
syphilis the reverse is the rule. 

Typhoid Fever. — There should be no difficulty, as a 
rule, in this form. 

Rheumatism, Traumatism, Exposure to Cold, Etc. — 
In rheumatism or gout there are usually other diagnostic 
symptoms. An examination of the urine will aid in obscure 
cases. 

In traumatism, the history will usually reveal the cause. 
The laryngoscopic image is similar in all these cases. 

Prognosis. — Tubercular. — Unfavorable, although the 
progress of the disease is slow ; when the larynx is seriously 
affected, a cure is impossible. 

Syphilitic. — While unfavorable, it is better than tuber- 
cular. The time it is seen, and the promptness of treatment, 
will largely determine the outcome. 

Typhoid Fever. — Unfavorable. The general condition 
will, however, have an influence. 

In the other types the prognosis is fairly favorable. 

Treatment. — Tubercular. — Improvement of the general 
debility is essential. Life in the open air and exercise 
within the point of fatigue. Plenty of fatty foods, especially 
such as are composed largely of the liquid fats, either ani- 
mal or vegetable. Especial attention must be given to the 



Simple Chronic Laryngitis. 461 

digestive tract. The use of veratrum, liquor potassii arsen- 
itis, and lactophosphate of lime will usually be indicated. 
When suppuration occurs, lime or silicea. When the disease 
has continued for some time, and there is extensive implica- 
tion of the structures, but little can be accomplished. 

Syphilis. — The treatment given under syphilitic rhinitis 
should be followed. The edematous engorgement of tissue 
may require either intubation or tracheotomy. 

Typhoid Fever. — Scarification and puncture may be nec- 
essary in the early stages. Intubation or tracheotomy may 
be required. Apis or apocynum, or the two combined, will 
often relieve the edema. For the suppurative condition the 
treatment does not vary materially from that already given 
for cartilaginous affections. 

Traumatism, Rheumatism, Exposure to Cold, Etc. — 
The use of aconite, apis, apocynum, saline cathartics, etc., 
should be used as indicated, also anti-rheumatic remedies, 
when rheumatism is the factor. 

Simple Chronic Laryngitis. 

Synonym. — Chronic catarrh of the larynx. 

Definition. — This is a chronic inflammation resulting 
in structural changes, either superficial or deep, of the 
laryngeal tissues. What is usually called the sub-acute 
form is really only the commencement of the chronic inflam- 
mation, the structural changes not being pronounced. 
Hoarseness, or loss of voice, is characteristic. Ulceration is 
sometimes found. 

Etiology. — Simple chronic laryngitis may result from, 
or be coincident with, repeated catarrhal inflammation Of the 
larynx or pharynx and, in some instances, of the nose. In- 
vasion of the larynx through continuity of tissue is probably 
more infrequent than is usually supposed, as the causes 
producing morbid conditions of the nasal or pharyngeal 
tissues would also affect the laryngeal. 



4.62 Nose, Throat and Ear. 

In cases where there is an accumulation of secretion in 
contact with the larynx, the irritation so produced may be 
an exciting cause, and the efforts of the patient to clear 
the throat will increase the inflammatory action. Inflamma- 
tion of the contiguous esophagus may be a factor in laryn- 
geal catarrh. As a sequel of la grippe, a chronic catarrh 
is often a persistent feature, the infiltrated material appar- 
ently differing from the usual exudate. Continuous expos- 
ure to an atmosphere charged with irritating material will 
eventually produce a catarrhal state. Constitutional dis- 
turbances in which there is lowered resistance or circulatory 
wrongs may predispose to chronic catarrh. Where there 
is faulty nasal respiration, either through obstruction of the 
nasal cavities, resulting in mouth breathing, or through ex- 
cessive atrophy or destruction of nasal structures from any 
cause, so that the air is not properly prepared for entering 
the larynx, chronic laryngitis is quite frequent. 

Excessive or faulty use of the voice is also a cause. 
The abuse of alcohol and tobacco may also produce the 
disease. Abnormal conditions in the pharynx, or an elon- 
gated uvula, hypertrophied faucial or lingual tonsils may 
be exciting factors. Atmospheric changes, when the other 
portions of the respiratory tract are healthy, will produce 
no effect; but otherwise, such changes are frequently excit- 
ing factors. 

Pathology. — The changes vary according to the exciting 
cause. If the irritation is constant, with slow inflammatory 
action, allowing proliferation of the exudate and fixed con- 
nective tissue cells, the submucosa will be affected. En- 
gorgement of the blood-vessels, causing permanent dila- 
tation, may also cause thickening, through secondary 
changes. The epithelial layer will be affected in either case, 
and the changes may be either in the mucous membrane or 
in the deeper muscular tissues. When the deeper tissues 
are affected the symptoms are more pronounced, and the 
structural changes more permanent. 



Simpi,k Chronic Laryngitis. 463 

If the mucous membrane of the ventricular bands be- 
come permanently thickened, there will be a change in the 
vocal cords, either by the inflammatory action, or on account 
of the implication of the intrinsic muscles and abnormal 
circulation. The change in voice is marked when perma- 
nent connective tissue changes have occurred. 

Symptoms.— These are both objective and subjective. 
The quality of the voice is irregular, and conversation in- 
clined to spasmodic pronunciation. The patient complains 
of the throat aching or feeling fatigued. When not trying 
to talk, there may be no particular indication of wrong, or 
there may be a sensation of dryness or irritation. After 
sleeping and also after eating the secretions are profuse 
and there is more or less hawking or coughing until the 
excess of secretion is removed. 

A tickling sensation is usually present, interfering with 
the articulation of words on account of the attendant cough. 
Complete loss of voice at times, even w r hile talking, is not 
uncommon, the voice returning as suddenly as it was lost. 
A rough or rasping feeling is often spoken of by the pa- 
tient. In some cases the voice will be husky when the 
patient begins to talk, and after a few minutes it will be- 
come clear, and, if the conversational effort is prolonged, 
the voice wijl sink to a whisper. 

In uncomplicated cases the secretion is not usually pro- 
fuse, but is tenacious, varying in color from a frothy white 
to a yellowish or even pus-like secretion. At times the secre- 
tion may be tinged with blood. 

On inspection, the laryngeal membrane presents a pe- 
culiar reddened, boggy, or edematous appearance. Blood- 
vessels may often be distinctly seen on the epiglottis or 
within the larynx. At the base of the cords the tissue will 
be swollen, as well as within the ventricular bands. The 
vocal cords are usually involved secondarily. Superficial 
ulceration sometimes occurs, but more frequently localized 



464 Nose, Throat and Ear. 

areas of desquamation are formed, and usually between the 
arytenoid cartilages. 

Diagnosis. — This disease may be mistaken for edema, 
paralysis, malignant growths, tuberculosis, or syphilis. 

Edema. — -The swelling comes on rapidly, and is more 
marked. 

Paralysis. — Swelling slight, if any. The odor of re- 
tained secretion, continuous hoarseness, and lack of move- 
ment of the larynx. 

Chronic Laryngitis. — Hoarseness variable, and most 
marked mornings and after eating. Mobility of the larynx 
lessened. The effort to use the voice may temporarily clear 
it, but the symptoms usually return with increased sever- 
ity, differing in- this from edema, paralysis, syphilis, or 
tuberculosis. The history is most important. 

.Tubercular Laryngitis. — The history and general condi- 
tion of the patient. 

Syphilitic Laryngitis. — History when obtainable. Amel- 
ioration of the symptoms with antisyphilitic remedies. 
Healing usually results in a stellate scar well up in the 
larynx. Edema not localized and produces dyspnea. In 
the so-called tertiary stage localization may occur, the re- 
sult of chondritis or perichondritis. 

Malignant Disease. — The age and history must be con- 
sidered. Glandular affection occurs late in carcinoma. 
Edema is slight until characteristic symptoms are present. 
Changes in the voice occur early, and a catarrhal condition 
is always present. With the increase of growth, swelling 
and edema result, and later ulceration. The odor is very 
similar to that noticed in paralysis. Severe hemorrhage 
often occurs after ulceration commences. Pain is severe 
and lancinating. 

Prognosis. — When seen before much structural change 
occurs, many cases can be cured. After structural changes 
have occurred, the permanent restoration of the natural 
voice is impossible. 



Follicular Laryngitis. 465 

Treatment. — Any nasal anomalies should be corrected. 
The nasopharynx and pharynx should be kept as free from 
accumulated secretion as possible, and for this purpose the 
salicylic acid wash is one of the best preparations. Inter- 
nally collinsonia, phytolacca, hydrastis, apis, apocynum, po- 
tassium bichromate, jaborandi, bryonia, rhus, lime in some 
form, and potassium iodide. 

The general health should receive attention, but usually 
when the proper remedies are employed for the catarrhal 
state, the general condition will improve. Rest of the laryn- 
geal structures is imperative for satisfactory results. 
» 

Follicular Laryngitis. 

Synonyms. — Granular laryngitis ; Glandular laryngitis. 

This is an inflammatory condition usually starting in and 
affecting primarily the entire mucous membrane, and local- 
izes in the small racemose gland-structure. Follicular 
pharyngitis may be associated with it. Minute elevations 
caused by the retained secretion will be seen. Ulceration of 
these elevations may allow the escape of the secretion. 

Etiology. — The mucous follicles are not numerous, and 
are mostly situated on the lateral and posterior surfaces. 
They are most frequently associated with systemic wrongs, 
or following fevers or wasting diseases where glandular 
secretion is abnormal. In persons who use the voice con- 
siderably, vascular engorgement of the mucous membrane 
temporarily obstructs the glandular secretion. In gouty 
patients, and in the so-called uric acid diathesis, it is also 
sometimes seen. 

Pathology. — Practically the same as in follicular pharyn- 
gitis. 

Diagnosis. — The laryngoscopic image will usually deter- 
mine the condition. 

Prognosis. — If seen early, it is good. If permanent 
30- 



466 Nose, Throat and Ear. 

changes have taken place in the tissues, relief from the most 
annoying symptoms may be all that can be accomplished. 

Symptoms. — Usually referred to the larynx. A tickling 
sensation and frequent effort or desire to clear the throat 
is generally present. Cough may be present, but is volun- 
tary, unless complicated by tracheal or bronchial inflamma- 
tion. The cough is often dry and expectoration scanty ; if 
profuse, it results from associated inflammatory conditions. 
Changes in the voice vary, and are not characteristic. Some 
hoarseness results from the adherent mucus, hyperemia, or 
congestion. The symptoms do not differ materially in un- 
complicated cases from simple chronic laryngitis. , 

Treatment. — The causative factor should be determined. 
If due to the patient's vocation, this should be changed if 
possible. When the result of systemic derangement, relief 
will follow its elimination. For the laryngeal condition, 
the remedies given under simple chronic laryngitis will be 
required. 

Dry Laryngitis. 

Synonyms. — Atrophic laryngitis ; Laryngitis sicca ; 
Ozena laryngis. 

In this affection the secretion is retained upon the mu- 
cous surface and forms crusts. 

Etiology. — This condition is usually associated with 
atrophic pharyngitis, and sometimes the same condition of 
the nasopharynx and nares. The causative factor, whether 
local or constitutional, which affects the latter structures, 
may affect the larynx, but not so frequently. Whatever the 
cause, there is a change in the submucosa and impaired 
glandular action. The character of the secretion varies, ac- 
cording to the tissue and glandular changes. The respira- 
tion of over-heated, gas-laden air is an especially important 
factor. 

Pathology. — The accumulated secretion is composed of 
inspissated mucus, holding desquamated epithelium and 



Dry Laryngitis. 467 

leukocytes. The secretion contains an excess of fibrin, and 
a deficient amount of serum. The bacillus foetidus often 
invades this exudate, causing an offensive breath — the so- 
called laryngotracheal ozena. The crusts are most fre- 
quently below the vocal cords. In many cases there is slight 
crust formation, the surface being dry and glazed. This is 
the case usually when the disease is due to a systemic lesion, 
the laryngeal affection being secondary. A true atrophic 
state of the laryngeal tissues is infrequent, the condition 
partaking more of the character of dry laryngitis, through 
perversion of secretion. The changes in the tissue are not 
so decided as in the nasal and pharyngeal region. 

Symptoms. — These vary considerably. The symptoms 
during the day are not so marked as during sleep. In the 
latter, the recumbent position favors the accumulation of 
mucus and formation of crusts, which will produce parox- 
ysms of coughing, weakening the patient. Difficult respira- 
tion and change in the voice may occur. As a result of the 
laryngeal accumulation considerable irritation is produced, 
causing violent paroxysms of coughing, during which some 
of the secretion may be expelled, affording temporarv re- 
lief. When there is not the tendency to crust formation, 
and the tissues are dry and glazed, there is not the day and 
night difference in symptoms. The cough is more contin- 
uous and sudden changes in tone are frequent, but respira- 
tion is slightly, if at all impeded. When the accumulated 
material is expelled it resembles that found in atrophic 
pharyngitis or rhinitis. Occasionally the secretion is slightly 
stained with blood, the result of capillary hemorrhage, and 
this will often alarm the patient. 

Diagnosis. — This is made by the subjective symptoms 
and a laryngeal examination. The crusts may be mistaken 
for ulcerative areas. The affection is usually subglottic. 

Prognosis. — As the condition is essentially chronic, and 
the structural changes depend upon the time the disease is 



468 Nosb, Throat and Ear. 

recognized, the prognosis is necessarily guarded. More or 
less relief, however, can usually be promised. 

Treatment. — The general health should be improved, 
and if the disease is due to some systemic condition, this 
should be corrected. Drugs influencing glandular structures 
are necessary. The use internally of jaborandi, phytolacca, 
iris, collinsonia, hydrastis, potassium bichromate, potassium 
iodide in small doses or ammonium iodide in fractional 
grain doses will increase glandular activity. The use of 
local applications is liable to do more harm than good. 

Cyanotic Laryngitis. 

Synonyms. — Angio-neurotic edema; Chronic edema; 
Symptomatic laryngitis. 

This condition has already been described in the. anterior 
nares and nasopharynx. The lesion in the larynx is very 
similar to that in either of the two mentioned. 

Symptoms. — Practically those of chronic pharyngitis. 
Mackenzie describes under the heading phlebectasis laryngea 
practically this condition, it being a varicosed state of the 
veins, of the epiglottis, arytenoids, and ventricular bands. 

Prognosis. — This depends upon the cause, and whether 
it is amenable to treatment. 

Treatment. — This must be directed to the causative fac- 
tor. Cardiac and renal remedies are most frequently re- 
quired, as cactus, glonoin, strophanthus, Crataegus oxy- 
cantha, apis, apocynum, digitalis, elaterium. 

Hyperplastic Laryngitis. 

Synonyms. — Hypertrophic laryngitis ; Hypertrophy of 
the laryngeal tissue. 

This is infrequently seen. It is the result of proliferation 
of fixed connective tissue cells, rather from a slight irrita- 
tion than an inflammation. If from the latter, complete 
organization and contraction does not occur. The thicken- 



Hyperemia of the Larynx. 469 

ing is permanent, and there is some obstruction and inter- 
ference with the mobility of the larynx. The cause is not 
understood, and treatment gives no relief. 

Anemia of the Larynx. 

This is a local manifestation of a systemic condition. 
The blood supply is deficient, and vascular tonicity sub- 
normal. The tissues are lax and boggy. Venous stasis and 
seepage from the relaxed vessels is the cause of the boggy 
condition of the tissues. Change in the tone and power of 
the voice may result, or the edema may be so marked as to 
cause aphonia. Change in the tissues is slight, unless asso- 
ciated with other lesions. 

Diagnosis, prognosis, and treatment depend upon the 
causative factor. 

Hyperemia of the Larynx. 

This condition is found in persons where there is simply 
irritation enough to cause a localized increase of blood to 
the part, but not sufficient to produce inflammation. Voca- 
tion is a factor. Excessive use of alcoholics or tobacco may 
produce a very similar condition. 

Pathology. — The hyperemia may be diffuse or irregu- 
larly distributed. It may be either sub- or supra-glottic, 
or both. Changes in the tissues are slight. 

Symptoms. — In plethoric persons with overstimulation 
of the circulation, a slight hemorrhage may occur, the voice 
is somewhat changed, being irregular and imperfect in tone, 
and a more or less constant desire to clear the throat, with 
sometimes a hypersecretion. Pain is absent in uncompli- 
cated cases. 

Treatment. — Removal of the exciting cause is most im- 
portant. Internally the remedies already recommended for 
laryngeal affections. 



470 Nose, Throa? and Ear. 

Pemphigus of the Larynx. 

This infrequent inflammatory condition is characterized 
by an eruption of vesicles very similar in appearance to 
herpes of the skin. The vesicles are most frequently on the 
ventricular bands and arytenoid surfaces, their formation 
being preceded by mild systemic symptoms, rigor, and some 
increase of temperature. The throat is sore, and there is 
a sharp, cutting pain increased on deglutition, also change 
in the voice. Inspection will reveal a similar condition of 
the faucial and pharyngeal tissues. Some edema may sur- 
round the vesicles. The eruption may accompany alimen- 
tary wrongs, or may follow typhoidal or suppurative con- 
ditions. Usually the vesicles rupture in a few hours, leav- 
ing small, superficial ulcers. 

Treatment. — Intestinal lesions should be corrected, and 
such remedies employed as will restore the secretions r to 
normal. 

Singer's Nodules. 

Synonyms. — Chorditis tuberosa ; Trachoma ; Trachoma 
of the larynx ; Trachoma of the vocal cords ; Pachydermia 
laryngis. 

This is a new growth resulting from inflammatory ac- 
tion, and is located within the vocal cord, affecting the 
margin, and most frequently between the anterior and mid- 
dle thirds. The growth is a small ovoid nodule, located at 
the edge of the cord. The growth may be single or multiple, 
both cords may be affected simultaneously, or one later on, 
and are usually opposite each other. 

Etiology. — This is an inflammatory condition with in- 
flammatory organization, resulting in continued interference 
of phonation after the active action has subsided. The sup- 
position is that the improper use of the vocal organs, and 
the frequent and sustained efforts required for certain tones, 
is an important factor. In the middle or upper middle reg- 



Singer's Nodules. 471 

ister the vocal cords are practically retained in the same 
position, and the extrinsic and intrinsic muscles sustain a 
relatively continuous tension. Singers, or those using the 
voice a great deal, are most liable to this condition. Other 
factors to be considered are, the use of the voice when the 
surrounding tissue of the vocal cords is congested directly 
01 indirectly with inflammation of the laryngeal structure ; 
excessive use of the voice when the cords are hyperemic 
from violent exercise. Circumscribed hemorrhagic areas, 
with localized inflammation, occurring during or following 
la grippe in which laryngeal complications were present, 
have been noted. A tubercular tendency appears to be a 
predisposing cause. A subnormal vascular tonicity may be 
an indirect causative factor. 

Pathology. — This appears to be practically like the re- 
sults from an inflammatory change. The fact that there is' 
no tendency to increase in size, shows it is truly an inflam- 
matory process. Some consider the swellings to be of 
glandular origin, but this is hardly tenable, as gland element 
is absent in the vocal cord structure. 

Symptoms. — Principally the change in the voice, which 
varies according to the stage of the disease and implication 
of the cords. It may be simply a slight hoarseness, or com- 
plete loss of voice. The patient is apprehensive, which in- 
creases the irregularity of vocalization. Paresis of the 
tensor muscles and a chronic laryngitis are usually present 
in complete aphonia. As the nodule becomes more fibrous 
and affects the surrounding tissue in contracting, the voice 
changes more markedly. 

Diagnosis. — By the history and the laryngoscopic mir- 
ror. During the early stage the nodule is reddened; later, 
whitish or grayish white. The size is variable, from about 
the size of a millet-seed up. When only one cord is affected, 
the fellow cord may have a corresponding depression. If 
multiple and on one cord only, an undulating edge results. 



472 Nosk, Throat and Ear. 

The chance of an early stage of a malignant growth must 
be considered. 

Prognosis. — Fairly favorable in the early stage, and 
when but one nodule is present. If of long standing, and 
fibrous tissue formation and contraction have occurred, res- 
toration of the voice is unusual. 

Treatment. — Although some benefit has been obtained 
by careful exercise of the muscles, especially the intrinsic, 
other measures are usually required. Operative procedures 
will depend upon the location and size of the nodule, also 
whether single or multiple, pedunculated or sessile. If pe- 
dunculated, the laryngeal cutting forceps will readily re- 
move the growth. If sessile, and seen early, crushing the 
nodule with blunt forceps may give fairly good results. 
Local applications of a three per cent solution of zinc chlo- 
ride, or ferrum perchloride to aqua §j, is recommended by 
some operators. 

Chronic Inflammations of the Larynx. 

Syphilis op the) Larynx. 

Synonyms. — Specific laryngitis ; Laryngitis specifica. 

This is a syphilitic inflammation which may show sec- 
ondary or tertiary lesions similar to those occurring in other 
parts of the body. In the secondary lesions there may be 
erythema, superficial ulceration, mucous patches, and small 
condylomata. In the tertiary form there are gummata, deep 
and extensive ulceration, and later cicatrization. The dis- 
ease may be acquired or hereditary, and may appear at 
any age. 

Etiology. — Primary infection is practically unknown, but 
is a possibility. Both secondary and tertiary manifestations 
may occur in acquired syphilis, but the tertiary form is by 
far the most frequent in the hereditary disease. In the 
acquired form the tertiary type is most frequent, and may 



Syphilis of the Larynx. 473 

develop years after the initial lesion. Males are most often 
affected, and the winter season appears to develop the con- 
dition most frequently. Age is not a factor. 

Pathology. — This is the same as in nasal syphilis. 

Symptoms. — No characteristic symptoms of the disease 
are present. Usually subjective symptoms are slight, and 
the condition is supposed to be merely a cold, but occasion- 
ally there is severe pain, and between these extremes all con- 
ditions may exist. In the secondary lesions the general 
symptoms are very like those of the tertiary type, only dif- 
fering in degree. The most pronounced is the change in 
the quality of the voice. Phonation may be difficult and 
painful, or even aphonia may occur. Paralysis of the vocal 
cords sometimes occurs early, and is generally unilateral. 
A short, hacking cough is frequently an annoying feature. 
The expectorated material varies from a thin serous ma- 
terial, through the different grades, to the offensive necrotic 
discharge of the later stages. The amount of discharge 
from the larynx is slight, and is best observed from the 
larynx with the laryngoscopy mirror. The pain usually 
depends upon the amount of ulceration and irritation, and 
is less severe than in tubercular laryngitis. Dysphagia may 
occur, and dyspnea in the later stages of gummata, or cica- 
tricial contraction may become marked. Localized pain and 
tenderness may be considerable. Hemorrhage may occur, 
but is infrequent. In secondary syphilis the usual con- 
ditions are erythema, superficial ulceration, mucous patch, 
and condyloma. 

Erythema. — This may follow the primary lesion within 
a few weeks, but usually occurs four or five months later, 
often following the disappearance of the cutaneous erup- 
tion. The laryngoscopic image will reveal, either areas or 
the entire surface of the posterior portion of the epiglottis, 
the aryepiglottic folds, false cords, and occasionally the 
vocal cords, with an inflammatory turgescence. The con- 



474 Nose, Throat and Ear. 

gestion may be uniform, and appear like a simple catarrhal 
condition. In typical cases a mottled appearance is noticed. 
Sometimes the vocal cords are infiltrated and swollen. 
There is neither pain nor difficulty in swallowing, but there 
may be some cough. Hoarseness or complete aphonia may 
result when the vocal cords are affected. Proper treatment 
rapidly relieves the condition, and makes the diagnosis 
certain. 

Superficial Ulckr. — This lesion is located practically 
the same as the erythema, and results from necrosis of the 
syphilitic inflammatory material in the upper layers of the 
membrane, or from disintegration of a mucous patch. The 
shape is irregularly rounded, having an inflammatory areola 
surrounding it. The ulcer is shallow and covered by a yel- 
lowish, sanious material. One ulcer may heal and another 
form elsewhere, the condition being chronic. This dispo- 
sition to recur has been termed recurrent ulcerative laryn- 
gitis. When upon the vocal cords the lesions are so minute 
that they are often overlooked. The characteristic stellate 
scar usually is seen after healing occurs. The symptoms 
are usually slight. There is not much pain as a rule, but it 
is proportionate to the extent of the lesion. Expectoration 
is slight, and there is not much cough or vocal impairment.- 
Usually occurs between two and seven years after the initial 
lesion. 

Mucous Patch. — This condition is seldom seen, some 
denying its existence upon the laryngeal surface. Patches 
may occur simultaneously with the same condition of the 
pharynx or tongue, or alone, usually on the supper surface 
and free margins of the epiglottis, the arytenoid structures, 
and vocal bands. They have never been observed below the 
vocal cords. The patches have a regularly rounded appear- 
ance, the margins slightly elevated, and the surrounding 
tissue reddened and inflamed. The area is whitish, or cov- 
ered with a yellowish, pultaceous material, which may be 



Syphilis of the L,arynx. 475 

stained with blood. The floor of the lesion may be the site 
of rapid, persistent granulations. The areas may be painful 
to probe palpation. Multiple or single areas may be present, 
and a well defined cicatrix usually follows healing. The 
virulent character of the secretion in this condition should 
be remembered. Recurrence is infrequent. 

Condylomata. — Occasionally these occur as small, yel- 
lowish papules with an elevated base. They are not often 
annoying, and generally disappear spontaneously. 

Tertiary Manifestations. — This type is usually that 
of hereditary syphilis, but when not the manifestations sel- 
dom appear before five years after the initial lesion. 

Gumma. — Most frequent in the epiglottis, upon the ary- 
tenoids, or the interarytenoid commisure, but no portion of 
the laryngeal structure is immune. The gumma may be 
single or multiple. They appear first in the deeper layers 
of the membrane, and are small, smooth prominences, the 
same color as the surrounding membrane. The growth is 
slow, and when fully developed they vary from the size of 
a pinhead to a small marble. Inflammatory symptoms sel- 
dom precede the condition. When fully developed, soften- 
ing follows, a yellow spot appears in the center, rupture 
of the overlying tissue and escape of the morbid material 
occurs, a deep and destructive ulcer forming. Usually the 
destructive process is rapid, but sometimes it may be slow, 
or even absent. The symptoms depend upon the size and 
location. When there is pain, it usually is a dull, deep-seated 
aching. Palpation may reveal tenderness. Discomfort on 
swallowing and change in the voice may follow. Cough is 
seldom present, but impaired respiration through occlusion 
of the respiratory tract may occur. Unilateral, and some- 
times bilateral, paralytic phenomena may occur, a peculiar 
stridor of the voice resulting. 

Tertiary Ulceration. — This results from gummatous 
degeneration, and is especially severe and destructive. 



476 Nose, Throat and Kar. 

After the gumma ruptures, a deep, foul, rapidly destructive 
ulceration follows. The site is usually on the free margins 
of the epiglottis, and nearly always unsymmetrical. The 
edges are sharply defined, but ragged, and the ulcer is filled 
with an offensive, greenish or yellowish, purulent, tenacious 
material, while the membrane surrounding the lesion is in- 
flamed and elevated. Coalescence of adjacent ulcers occurs, 
and the destructive process extends rapidly in depth and 
area. In the later stages the perichondrium is affected, and 
the laryngeal cartilages ulcerate and necrose. Any portion 
of the larynx may be involved in the destructive process, 
and the resulting condition is dangerous. The thyroid is 
usually the last to be affected, and in the latest stage of the 
disease. Pain is often constant and intense, dull and deep- 
seated. Pain on swallowing is often excrutiating. Severe 
dyspnea may present. 

Dyspjionia or aphonia may occur, while change in the 
voice is practically always present. The expectoration is 
mucopurulent in character, and dark, offensive particles of 
necrosed tissue, occasionally stained with blood, will be 
found. Hemorrhage seldom occurs. Small portions of the 
laryngeal structure may be expectorated or swallowed. In 
the later stages of the disease difficulty in swallowing is 
often present, and in eating, particles of food or fluids may 
enter the larynx, causing choking and strangling paroxysms. 
Following the perichondrial lesion, pain and tenderness may 
be intense. External swelling sometimes occurs. Recur- 
rent attacks are frequent. 

Cicatrization. — After the tertiary ulcerative stage, 
rapid cicatrization may follow with the resulting contraction 
and stenosis. The form of the larynx is permanently 
changed and also its functions. The subjective symptoms 
of the ulcerative stage are increased, and asphyxia may be- 
come imminent. This condition is more likely to follow re- 
current attacks. 



Syphilis of the Larynx. 



477 



Diagnosis. — The history when obtainable; the general 
condition; the result of specific treatment; and the local 
phenomena. The possibility of tubercular or carcinoma as 
a complicating condition must be remembered. In tuber- 
cular laryngitis, the membranes are pale, the ulceration 
shallow, and the inflammatory zone absent. There is more 
pain and but slight tendency to heal, besides there is usually 
a pulmonary lesion. In carcinoma prior to ulceration, there 
is a distinct, well defined tumor, and after ulceration the 
pain is sharp and lancinating. In lupus, ulceration may be 
absent, and cicatrization is not marked. 




Fig. 94. Cicatrization -and deformity resulting from 
syphilitic ulceration. 



Prognosis. — Usually favorable so far as life is con- 
cerned, although it may be extremely chronic in character. 
Impairment of function results in cases where there has 
been much destruction of tissue. The secondary lesions are 
more amenable to treatment than the tertiary, where sur- 
gical interference may be required in the later stages. 

Treatment. — Local. — In superficial ulceration, after 
thorough cleansing of the surface, touching the area with a 
solution of silver nitrate gr. xx to xl, aqua 5J, or thuja and 
Lloyd's Hydrastis aa will be required. The latter is prefer- 
able in the majority of cases. In secondary and tertiary 



478 Nose, Throat and Bar. 

lesions local treatment is important, but systemic measures 
are necessary for good results. The internal medication is 
the same as in syphilitic rhinitis or pharyngitis. 

Tuberculosis of the Larynx. 

Synonyms. — Consumption of the larynx; Consumption 
of the throat ; Laryngeal phthisis ; Tubercular laryngitis. 

This condition may precede, but usually follows or oc- 
curs simultaneously with pulmonary lesions. There is 
swelling of the laryngeal mucosa and development of 
miliary tubercles. Small spreading ulcers that become con- 
fluent and cause extensive ulceration follows the breaking 
down of these tubercles, resulting in changes in the structure 
of the larynx. 

Etiology. — The generally accepted theory is that it is 
caused by the Bacillus tuberculosis, or Bacillus of Koch. 
Primary infection of the larynx may occur, but it is usually 
secondary to pulmonary tuberculosis. A predisposing fac- 
tor is undoubtedly heredity, but a subnormal condition of 
the system will furnish nearly as many cases. The disease 
is found most often between the ages of twenty and thirty- 
five, and most frequently in males. 

Pathology. — Practically the same as in any other region. 

Symptoms. — These vary according to the individual, the 
location, extent, and progress. The usual location of in- 
vasion is upon the posterior region, this being due to the 
anatomical relations of the larynx. Usually the disease 
commences insidiously, and is variable in duration. One 
of the first symptoms the patient complains of is a dry, burn- 
ing sensation in the throat. Hoarseness and lack of vocal 
power soon follows. Often these symptoms have been pres- 
ent for some time, as an acute, subacute, or chronic laryn- 
gitis often precedes the tubercular lesion. Pain is usually 
absent in the earlier stages, but the sensation as if a foreign 
body was irritating or scratching the throat is often present. 



Tuberculosis of the L,arynx. 479 

After ulceration begins, the pain is usually marked. Ten- 
derness and pain on pressure may be severe. The change in 
voice is influenced by the location of the lesion. As a rule, 
there is hoarseness and lowered pitch, and sometimes 
aphonia. The effort to talk may be extremely painful. 
Cough is nearly always present, but is not always annoy- 
ing. Especially in the later stages, the cough may cause 
intense pain during a paroxysm. Swallowing becomes pro- 
gressively more painful, as a rule, while choking and stran- 
gling spells cause dread of attempting deglutition. In the 
late stage, regurgitation of food, and the entrance of par- 
ticles of food or of fluids into the larynx during inspiration, 
frequently occurs. There is not much secretion from the 
laryngeal tissues, but it is quite tenacious. In cases where 
there is apparently an excessive secretion, it is from the 
lungs. Particles of disintegrated cartilage may sometimes 
be ejected in the later stages. 

Dyspnea may occur at any time during the course of 
the disease, and may necessitate tracheotomy. Infrequently 
a condition of stenosis from partial cicatrization of an ul- 
cerative area may occur which will also demand operative 
interference. Besides the local symptoms, there will be 
the general manifestations of the systemic lesion. 

The laryngoscopic image is as varied as the clinical symp- 
toms. In the rapid type there is usually a hyperemic ap- 
pearance, while in the slow or chronic type an anemic con- 
dition is usually found. After the initial stage, localized 
swellings may be found, hyperemic in the acute type, but 
anemic in the chronic. These elevations increase in size, 
and may become so large that dyspnea results, especially 
when near the laryngeal entrance. The epiglottis is a fre- 
quent location for infiltration, and may assume a variety of 
forms. The arytenoid regions are often affected, and a 
certain rounded tumescence of the prominences has been 
termed "club-shaped" arytenoids. 



480 Nose, Throat and Bar. 

The membranes become more and more anemic and 
paler, and numerous bodies resembling small, yellowish 
seeds can be seen beneath the surface. The number in- 
creases, and degenerative changes occur, leaving small 
ulcers from the softening and escape of their contents. The 
formation of these necrotic spots introduces the final stage. 
Coalescence and extension of the process occurs. The ap- 
pearance of the larynx is changed according to the stage. 
The lesions may be small, shallow, and separate, with a 
tendency to spread; the floor irregular and bathed with a 
grayish, tenacious secretion, and the edges of the ulcer well 




Fig. 95. Tubercular ulceration of both cords. 

defined ; or there may be a large, roughened, irregular lesion. 
Implication of the cords may occur at any stage of the dis- 
ease. The appearance and conditions are about as varied 
as the individuals affected. 

Diagnosis. — Usually not difficult, particularly when pul- 
monary lesions are coincident with the laryngeal affection. 
In laryngeal tuberculosis the expectorated secretion from 
the larynx seldom contains the bacilli. Clinical symptoms, 
history, and amelioration of the condition by treatment, 
differentiate syphilis. The table of differential diagnosis 
by Joseph S. Gibb is valuable in distinguishing between the 
lesions likely to be mistaken for tuberculosis. 



Tuberculosis of the L,arynx. 



481 





Pain usually slight. 
Attacks any portion of the 

larynx, and ulcerates 

rapidly. 

Seldom seen in the stage of 
induration, the first evi- 
dence being a clear-cut, 
deep ulcer. 

Some induration around the 
ulcer, but usually very 
little edema. 

Ulcer extends deeply, often 
involving cartilage. 

Surface of ulcer covered by 
muco-purulent secretion 
and necrosed tissue. 

Mucous membrane hyper- 
emic and injected. 

Laryngeal stenosis not com- 
mon until cicatrization oc- 
curs. 

General health unimpaired. 

Frequent evidences of syph- 
ilitic disease in other tis- 
sues. 

• Rapidly improves under the 
iodides. 


< 

£ 
F 

M 

5° 


Pain constant, lancinating. 

Attacks any portion of the 
larynx, and ulcerates more 
slowly than syphilis. 

The first appearance is that 
of a new growth occupying 
the laryngeal cavity ; no 
clear-cut ulcer. 

The growth fills or encroaches 
on the laryngeal cavity. 

Growth extends in all direc- 
tions, involving all tissues 
in its course. 

Surface of growth covered by 
discharge. 

Mucous membrane hyper- 
emic. 

Laryngeal stenosis quite 
common. 

Early in disease no impair- 
ment of general health ; 
later on marked cachexia. 

In primary laryngeal carci- 
noma, no other involve- 
ment until later in the dis- 
ease. 

Iodides have no influence on 
the course of the disease. 




> 




g 

> 


Pain severe on deglutition. 

The favorite site is in the 
interarytenoid space or the 
base of the arytenoid car- 
tilage ; ulcerates slowly. 

Usually the first appearance 
is small spots' of indura- 
tion, which is rapidly fol- 
lowed by great edema. - 

Great edema of arytenoids. 

Ulcer extends laterally, but 
not deeply. 

Surface of ulcer covered by 
thick mucopurulent secre- 
tion and agglutinated 
mucus. 

Mucous membrane pale. 

Laryngeal stenosis rarely oc- 
curs. 

Health impaired previous to 
laryngeal involvement. 

Previous and coincident pul- 
monary trouble common. 

Iodides have no influence. 


H 
a 
u 
w 

n 
d 
r 


VJ 

en 


No pain. 

Attacks any portion ; ulcer- 
ates very slowly. 

Nodular masses. 

Little or no edema. 

Very slow in progress ; ul- 
cer seldom observed. 

Little or no discharge. 

Mucous membrane injected. 
Slight stenosis. 

Very slight impairment of 
general health. 

Frequently cutaneous mani- 
festations. 

Iodides have no influence. 


a 

09 





31 



482 Nose, Throat and Ear. 

Progn osis. — Usually unfavorable. 

Treatment. — The local treatment is the same whether 
the laryngeal lesions are primary or secondary. The sur- 
faces should be cleansed as thoroughly as possible, using 
the salicylic acid wash with hamamelis. After this process, 
the surface should be dried and very carefully touched with 
dilute nitric or dilute hydrochloric acid. No excess of the 
acid should be on the applicator. If the ulcer is deep, thor- 
ough curettement under local anesthesia should be done. 
Laryngectomy in primary cases will often effect a cure. 
The advice to seek another climate, while necessary in some 
cases, is usually a doubtful measure. For the relief of the 
pain, pineapple juice, used as a spray or with an applicator, 
will relieve many cases. Cocaine is very evanescent in its 
action. Chloretone used with an oily base often affords re- 
lief, but various remedies will have to be employed. The 
cough can often be controlled by the use of hydrastis and 
ergot, in dose of from gtt. v-xx of each in plenty of water. 
Other internal remedies for the disease are rhus tox, 
bryonia, collinsonia, phytolacca, liquor potassii arsenitis, 
potassium bichromate, veratrum. Cataphoresis is recom- 
mended by Scheppegrell. The food should consist of fatty 
substances, especially those containing a large amount of 
-the fluid fats. Plenty of fresh air should be insisted upon, 
as well as exercise short of fatigue. 

Laryngeal Hemorrhage. 

Laryngeal hemorrhage comprises rupture of a blood-ves- 
sel, with escape of blood into the submucous tissue, forming 
hematoma, and also an escape of blood from the surface of 
the mucous membrane. The interstitial and slight hemor- 
rhage causing inflammation has been given under hemor- 
rhagic laryngitis. 

Etiology. — Probably is usually the result of some sys- 
temic lesion. Occasional cases will be seen where the pa- 



Laryngeal Hemorrhage. 483 

tient seemingly is in good health. Any condition which 
may cause superficial congestion may produce laryngeal 
hemorrhage. 

Symptoms. — When the hemorrhage is confined to the 
submucous tissue, the symptoms usually are those of laryn- 
geal irritation, a disposition to cough, alteration of the 
voice, and if a hematoma of much size occurs, difficulty in 
breathing. A slight effort will cause the ejection of blood 
in streaks or masses, without being mixed with mucus or 
saliva; or the blood may be clotted by retention in the 
larynx, then expelled as small, dark colored masses, and 




Fig. 96. Fibroid polypus on the left vocal cord. 

without much change in the amount for several days, is a 
characteristic symptom. 

Prognosis. — Usually favorable as concerns life. 

Treatment. — When the hemorrhage is in the form of a 
hematoma encroaching upon the lumen of the larynx, and 
causing difficulty in breathing, the tumor should be incised 
and the clot removed. If the hemorrhage is from the sur- 
face, the internal use of ergot, hamamelis, carbo veg. iX. or 
belladonna is required. Systemic wrongs should be looked 
for and corrected so far as possible. For the irritation 
from small hemorrhagic areas, causing a cough, collinsonia, 






484 Nose, Throat and Bar. 

sanguinaria nitrate, or morphine sulphate in 1-1000 gr. 
doses will usually relieve. Avoidance of active exercise and 
use of the voice should be insisted upon. 

Foreign Bodies in the Larynx. 

Usually the entrance of foreign bodies into the larynx 
or the respiratory tract below, is a serious matter. The ma- 
terial may enter during mastication, deglutition, inspiration, 
or speaking. The severity of the symptoms depend largely 
upon the size, location, and character of the body. 

Two divisions may be made, fluid and solid. Fluids may 
be liquid food, the purulent material from tonsillar or retro- 
pharyngeal abscesses, blood during operative procedures or 
severe nasal hemorrhage, and vomited material. Solids 
may be classed as animate and inanimate, and comprise 
anything that can find entrance into the structure. Anom- 
alous or morbid conditions of the throat or larynx induc- 
ing anesthesia; fistulas, connecting the respiratory and ali- 
mentary tracts, or stricture of the esophagus, causing re- 
gurgitation of food, may be predisposing factors. 

Symptoms.— Usually when a foreign body has entered 
the respiratory tract, there will be choking or gasping for 
breath, dyspnea being most pronounced on inspiratory ef- 
fort. The facial expression is that of anxiety and often of 
suffering. Exophthalmos, and in severe cases, congestion 
of the face and neck may occur. A fatal termination may 
result, or the symptoms may gradually subside, with prac- 
tically normal respiration, but when the foreign body is not 
removed, there are usually recurrences of the attacks, caused 
either by a change in the position of the patient or of the 
foreign body. If the foreign body is angular or sharp, the 
distress is usually greater than when it is smooth. Em- 
physema of the neck and upper portion of the chest may 
follow when there is rupture of some portion of the respira- 
tory tract. Hemorrhage may follow erosion of the mem- 



Foreign Bodies in the Larynx. 485 

brane. A paroxysmal hoarse cough and loss of voice often 
result. The cough may partake of the characteristics of 
whooping-cough. Inflammation and ulceration may follow. 

Diagnosis. — Usually not difficult, as the history and in- 
spection will be sufficient. Palpation of the larynx may re- 
veal the presence of a foreign body, when a laryngoscopic 
view is impossible. In doubtful cases the X-ray is of value 
in determining the presence of, a foreign body. 

Prognosis. — Guarded. 

Treatment. — The use of sternutatories and emetics 
should be avoided. Inversion of the patient may cause dis- 
lodgement of the body, if smooth. If the offending sub- 
stance can be located in the larynx, it can usually be. re- 
moved with laryngeal forceps. If all other methods fail, 
operative measures will be required. 



CHAPTER XX. 
NEUROSES OF THE LARYNX. 

Nervous cough. Mogiphonia. Anesthesia. Paresthesia. 
Hyperesthesia. Neuralgia. Hysterical Aphonia. Chorea of 
the Larynx. Dysphonia Spastica. Laryngeal Vertigo. 

Paralysis of the'Vocal Cords, (a) Paralysis of the Su- 
perior Laryngeal Nerves. (b) Recurrent Laryngeal 
Paralysis, (c) Bilateral Abductor Paralysis, (d) Uni- 
lateral Paralysis of Abductors. 

Paralysis of Individual Muscles, (a) Paralysis of Cen- 
tral Adductors (Arytenoids), (b) Paralysis of Internal 
Tensors (Thyro-arytenoids). (c) Bilateral Paralysis of 
Adductors (Lateral crico-arytenoids). (d) Unilateral Ad- 
ductor Paralysis (Lateral crico-arytenoid) (Kyle). 

Nervous Cough. 

In neurotic individuals there may be a croupy, spas- 
modic, even musical cough, which is truly of nervous origin. 
In the majority of cases the cough is most annoying dur- 
ing the waking hours, and may be either almost incessant 
or paroxysmal, but usually it is a short barking cough in- 
creased by excitement, when choreic facial twitching may 
be present. During sleep it may be absent, but is some- 
times worse during sleep, and comparatively absent during 
the day. Again it may be practically continuous, no cessa- 
tion during the day or night. Sex is not so much a factor 
as a neurotic condition. 

Diagnosis. — This must be by exclusion. The thorax, 
nose, ears, nasopharynx, pharynx, fauces, larynx, alimen- 
tary, and generative systems should be examined for some 

486 



Anesthesia. 487 

condition which may cause a reflex cough. When no defi- 
nite lesion or condition can be found, the cough is probably 
strictly nervous in character. 

Treatment.— The general health should be improved 
when possible. For the cough the following has proven 
efficacious in the majority of cases. I£ Rhus tox., gtt. iij ; 
Morphine sulphate, gr. 1-8' Aqua §viij. Teaspoonful every 
five minutes until the cough is less annoying, then every 
half hour or hour. Gelsemium, pulsatilla, or ipecac may be 
indicated, but the dosage must be very small. Other reme- 
dies may be indicated. 

Mogiphonia. 

This term is used to designate a lack of tension of the 
vocal cords, where an extra effort in phonation is required. 
In ordinary conversation the voice may be normal, but 
when an extra exertion is necessary, the voice fails. 

Treatment. — Massage, friction, and rest of the vocal or- 
gans is necessary. Internally collinsonia, coca, hydrastis, 
nux, or ignatia will aid in recovery. 

Anesthesia. 

Etiology. — Induced anesthesia will not be considered. 
Subjective causes may be hysteria, epileptic attacks, cata- 
lepsy, the later stages of cholera, paralysis of the insane, 
bulbar paralysis, diphtheria, erysipelatous or variolous af- 
fections of the larynx, cerebral lesions of any character, 
posterior spinal sclerosis, progressive muscular atrophy, 
railway spine, lesions of the superior laryngeal nerve or of 
certain fibers of the pneumogastric, may produce anesthesia 
of the larynx. 

Symptoms. — Choking or coughing, through food or 
liquids entering the trachea, is the most marked symptom. 
Septic pneumonia often results in this condition. The 
laryngoscopic examination may show an erect epiglottis 



488 Nose, Throat and Ear. 

owing to paresis of the thyro- and ary-epiglottic muscles. 
Mackenzie has noted a waviness of the outline of the glottis 
in this condition. 

Diagnosis. — The lack of sensitiveness when the larynx 
is touched with a probe, and also absence of any reflex ac- 
tion. 

Prognosis. — Most favorable when it follows or is de- 
pendent upon diphtheria. When due to intracranial or 
spinal lesions, it is unfavorable. 

Treatment. — This must be directed to the cause. The 
.use of electricity has been recommended, as well as mas- 
sage. 

Paresthesia. 

Under this title are grouped the perverted sensations as 
of constriction, feeling as of a foreign body, heat, prickling 
or tickling. Any of these may result from morbid condi- 
tions outside of the laryngeal structure. Hypertrophy of 
the faucial tonsils or cryptic concretions of the same ; mor- 
bid changes of the lingual tonsils ; follicular pharyngitis, 
elongated uvula, varictfsed veins at the base of the tongue, 
adenoids, etc. In some systemic diseases and neurasthenics, 
any of these sensations may be present. Before classing 
the condition as purely nervous, a careful examination of 
jthe entire respiratory tract should be made. 

Treatment. — This will depend upon the cause. When 
of neurotic origin, suggestion will usually be most bene- 
ficial. 

Hyperesthesia. 

The normal sensitiveness of the laryngeal membrane 
varies in different persons, but when it is very marked, it 
may be called hypersensitive. Acute or chronic laryngitis 
is a common cause of this condition. Systemic diseases as 
incipient phthisis, gouty or rheumatic conditions, erosions, 
or ulcerations, tumors, etc., may be factors. 



Hysterica^ Aphonia. 489 

Symptoms. — A markedly aggravating cough, which may 
be convulsive and cause gagging whenever any slight irri- 
tation is present, or the deglutition of certain substances, 
are the usual symptoms. 

Treatment. — When due to systemic wrongs, these should 
be treated. Anomalous conditions of the surrounding 
structures should be corrected. Abrasions, ulcerations or 
fissures should be cleansed and treated with a strong solu- 
tion of silver nitrate or even the fused stick. 

Neuralgia. 

A true neuralgic pain in the larynx seldom occurs, but 
when it does, it usually- is due to some lesion of the larynx 
or surrounding tissue. 

Treatment. — The causative factor must be looked for. 
For the neuralgic pain, gelsemium, aconite, rhus tox, 
bryonia. 

Hysterical Aphonia. 

Synonym. — Functional aphonia. 

This consists of a sudden loss of voice, or complete 
aphonia, and most frequently occurs in neurotic, hysterical 
persons, especially in females between puberty and the 
menopause. Shocks, fright, intense emotion of any kind, 
or anxiety, may produce this disturbance. It is not the re- 
sult of a morbid lesion, but from some cause there is a tem- 
porary loss of control of the adductor nervous supply, prob- 
ably through some transient cerebral excitement. It may 
come on gradually or suddenly. Sometimes on retiring 
with full possession of the faculty of phonation, on awaken- 
ing partial or complete aphonia will be present. This con- 
dition may continue but a few hours, or may last for days, 
when the voice will return in full force as quickly as it was 
lost. This condition may recur frequently or only at long 
intervals of time. 



496 Nose, Throat and Ear. 

Diagnosis. — This is made by both the general condition 
and by the laryngoscopy mirror. With the latter, the cords 
will be seen more toward the median line on attempted 
phonation, but they do not approximate, but return after a 
few seconds to the inspiratory position. Cough is present in 
hysterical aphonia, but is absent in true adductor paralysis. 
The employment of a general anesthetic to the excitement 
stage will show, by the return of the voice, that it is not a 
paralytic condition. 

Treatment. — This must be directed to the causative fac- 
tor of the hysteria, and is often difficult to find. Pulsatilla, 
ignatia, nux, gelsemium. Electricity has been employed, 
but has not been successful except in a limited number of 
cases. 

Chorea of the Larynx. 

Synonym. — Laryngeal nystagmus. 

This condition is characterized by recurrence during the 
waking hours of a sharp, dry, noisy cough, caused by a vio- 
lent involuntary spasm of the vocal cords, occurring at 
varying intervals. It is found most often in girls at about 
the age of puberty. The sound differs from a true cough, 
as there is not the preliminary inspiration, the act being an 
expiratory bark or yelp diminishing in intensity. Choreic 
symptoms of other parts of the body may be present. Some- 
times the articulation is spasmodic but the tone is not 
changed. When the attack begins, the vocal cords may be 
seen to suddenly come together, and after a very short in- 
terval retreat close to the sides of the larynx. Expulsive 
effort of the thoracic muscles result from this spasm, and 
the glottis is forcibly opened with the characteristic sound. 

Treatment. — The correction of any abnormal condition 
of the respiratory tract. The affection is essentially chronic, 
and not easily relieved. The internal administration of 
Pulsatilla, ignatia, cimicifuga, viburnum, senecio, bryonia, 
jaborandi, sepia, rhus tox., or gelsemium may relieve. The 



I^ARYNGEAI, VERTIGO. 491 

faradic or galvanic currents may afford relief. Nux and 
strychnine are usually contra-indicated. 

Dysphonia Spastica. 

Synonym. — Spastic paraplegia of the larynx. 

This is a spasm of the glottis occurring only during at- 
tempted phonation. It occurs in adults, and most often in 
females. Impairment of the voice, or even aphonia, pre- 
cedes the condition. The glottis is tightly closed, and con- 
tinues so during the effort to speak, and opens when the 
attempt to talk ceases. Excessive use of the voice appears 
to bring on an attack at times, and if the effort is con- 
tinued, some cyanosis may occur. The laryngoscopy pic- 
ture is normal until the cords approximate in phonation, 
when a tonic spasm results, and the cords may overlap. 
The laryngeal muscles are not affected in respiration. It is 
a chronic condition. 

Treatment. — Often unsatisfactory. Rest of the vocal 
organs is most important. Any abnormal condition of the 
respiratory tract should be corrected, or if of reflex origin, 
the exciting cause should be removed. Hygienic measures 
are important. The constant current is recommended, but 
often the results are unsatisfactory. Internally the use of 
gelsemium, rhus tox., collinsonia, jaborandi in full doses, 
Pulsatilla, or ignatia may be indicated. 

Laryngeal Vertigo. 

Synonym. — Spasmodic laryngeal occlusion. 

This is a very infrequent affection, and usually without 
premonitory symptoms, unless it be a slight cough caused 
by a tickling sensation in the larynx. Spasm of the larynx 
may occur in a person in apparently good health, causing 
giddiness, blurring of vision and even unconsciousness. 
This lasts but a few seconds, but spasmodic twitching of 
the face or extremities may occur, and the only feeling will 



492 Nose, Throat and eUr. 

be that of a momentary sense of confusion. Usually no 
cause can be assigned, although an acute or chronic laryn- 
geal inflammation, aggravated by over-exertion or nervous 
excitement may be exciting causes. The attacks are usually 
irregular, even months intervening between seizures. At 
the onset there is a deep sucking in of air, which being con- 
fined by the glottic spasm, increases the pressure in the 
chest, diminishes heart action, and causes syncope. ' A con- 
tinuation of these attacks impairs the entire system. The 
outcome is favorable under proper treatment, which is simi- 
lar to that of dysphonia spastica. 

Paralysis of the Vocal Cords. 

Paralysis of the Superior Laryngeal Nerves. — Sensation 
of the laryngeal mucous membrane ; the action of the crico- 
thyroid muscles, and also in part of the arytenoideus, is sup- 
plied by the superior laryngeal nerves. 

Paralysis of the superior laryngeal causes loss of sensa- 
tion in the laryngeal membrane, and impaired or complete 
loss of the voice. One or both sides of the larynx may be 
affected. 

Etiology. — It may follow diphtheria, overuse of the voice 
during an attack of acute or subacute laryngitis, or by an 
injury or section of the nerve. The paralysis is seldom 
complete unless the result of the later causes. 

Symptoms. — The most marked are hoarseness, inability 
to reach the higher notes, or a peculiar "sliding rise in the 
pitch of the voice during ordinary conversation, which is 
beyond the control of the patient." 

Diagnosis— -In a typical case of bilateral paralysis, the 
laryngoscopic picture is characteristic. The vocal cords ap- 
proximate in such a way as to divide the glottic aperture 
into two unequal parts. The lack of action of ^the crico- 
thyroid muscle and anesthesia of the larynx determines the 
diagnosis. In unilateral paralysis relaxation of the portion 



Recurrent Laryngeal Paralysis. 493 

of the implicated cord between the vocal process and the 
thyroid cartilage occurs. 

. Prognosis. — Usually favorable, the time of recovery de- 
pending upon the cause. 

Treatment. — Attention to the respiratory tract is neces- 
sary, as also is rest of the vocal organs. Massage, the fara- 
dic or galvanic current should be tried. Internally nux or 
ignatia is usually indicated. 




Fig. 97. Bilateral paralysis of the superior 
laryngeal viscera. Phonation. 

Recurrent Laryngeal Paralysis. 

With the exception of the cricothyroid and arytenoideus, 
all the laryngeal muscles are controlled by the recurrent 
laryngeal nerve. Paralysis of this nerve results in loss of 
motion of the affected side, as the cricothyroid produces no 
appreciable motion. 

Etiology. — Pressure on the nerve at some point is the 
most frequent cause. This is especially true on the left side 
on account of the anatomical relations. Enlarged lym- 
phatics, mediastinal tumors, esophageal cancer, pleuritic ad- 
hesions in the early stages of phthisis (usually on the right 
side); pleural effusion or pericardial sacs, may cause the 
paralysis. A central lesion from any cause may be an ex- 
citing factor, and also toxemia, by producing a toxic 
neuritis. Laryngeal inflammations may also have an in- 
fluence in producing this condition. 



494 



Nose, Throat and Ear. 



Symptoms. — When unilateral, it is feeble vocalization 
rather than hoarseness, but eventually the voice becomes 
stronger as the unaffected cord is finally approximated to 
the affected cord. If bilateral, complete aphonia usually 
results, the patient having difficulty even in whispering. 

Cough, dyspnea, etc., are usually accidental. 

Diagnosis. — In bilateral paralysis the laryngoscopy 
image shows the cords relaxed, occupying a position mid- 
way between adduction and pronounced abduction — the so- 
called cadaveric position. In unilateral paralysis the af- 
fected cord passes its normal position in the attempt to meet 




Fig. 98. Paralysis of left vocal 
cord during phonation. 




Fig. 99. The same on 
deep inspiration. 



the other, the arytenoid cartilage passing slightly in front 
and beyond that of the affected side. When the diagnosis 
is made, the nervous system, cervical region and thorax 
should be examined to find the exciting factor. 

Prognosis. — This will depend upon the cause. When 
resulting from diphtheria or similar affections, recovery 
usually occurs in one or two months. It is unfavorable in 
cases due to severe chronic diseases, or an abnormal factor, 
and unless relief is obtained fairly early, atrophic changes 
in the muscles will preclude much improvement. 

Treatment. — This must be directed to the underlying 
cause. 



Bilateral Abductor Paralysis. 495 

Bilateral Abductor Paralysis. 

The action of the posterior crico-arytenoid muscles is to 
separate the vocal cords during inspiration, and the nerve 
center controlling this action is located in the medulla. 

Etiology. — The most frequent cause of bilateral abductor 
paralysis is some lesion affecting the central nervous sys- 
tem, and extending to the medullary centers. Syphilis, 
posterior spinal sclerosis or neoplasms, constitute this group. 

More infrequent causes are aneurism, mediastinal tumor, 
goiter, and cancer of the esophagus or thyroid gland, which 
affect the recurrent nerve. 

Peripheral causes, as laryngeal inflammation, may pos- 
sibly be a factor, and also hysteria. 

Symptoms. — Gradually there is increased difficulty on 
inspiration, the attacks of "inspiratory dyspnea" increas- 
ing in severity and frequency. An inspiratory stridor re- 
sults, and the entrance of air to the lungs becomes labored. 
Increased excitement or exertion causes extreme shortness 
of breath. The expiratory function is quietly performed, 
and with the exception of some weakening of the voice, no 
change occurs. Cough and expectoration are difficult. 

Diagnosis. — With the exception of ankylosis of the crico- 
arytenoid articulations, which may result from esophageal 
cancer or tubercular laryngitis, the laryngoscopy picture is 
not liable to be mistaken for bilateral abductor paralysis. 
On inspiration, the cords approach the median line and are 
motionless. On expiration the cords are separated by the 
exit of the air. In phonation there is no abnormal move- 
ment. 

Prognosis. — This depends upon the cause. The slower 
the development, the less favorable. When the paralysis 
has continued for ten or twelve months, a return of muscle 
action is usually impossible. 

Treatment. — This must be directed to the cause. As 



496 Nose, Throat and Ear. 

asphyxiation may occur, the necessity for tracheotomy may 
be imperative. This is usually a better procedure than in- 
tubation. Section of both recurrent laryngeal nerves has 
been suggested, but according to Bosworth, while it would 
relieve the attacks of dyspnea, it would cause loss of voice. 

Unilateral Paralysis of the Abductors. 

Paralysis of one of the muscles of abduction (crico- 
thyroid) may result from (a) some central lesion, (b) 
pressure on the nerve in its course by an intra-thoracic 
aneurism, malignant disease, or thickening of the pleura, 
(c) acute inflammation or other intralaryngeal affections 
implicating the periphery of the nerve, or (d) gout, rheu- 
matism, diphtheria, plumbism, enteric fever, and the acute 
infectious diseases. 

Symptoms. — Usually not severe. Exertion may cause 
some shortness of breath, which is most probably due to the 
causative disease, and is not paroxysmal in character. The 
voice is unaffected. The laryng'oscopic image shows no 
abnormality during phonation, but during inspiration the 
cord on the affected side is motionless in the median line, 
the fellow cord being drawn aside normally. 

Prognosis. — Guarded, as both sides may become af- 
fected, and the cause may not be amenable to treatment. 

Treatment. — This must be directed to the causative fac- 
tor, and is similar to that given under bilateral paralysis of 
the abductors. Tracheotomy is never necessary. 

Paralysis of Individual Muscles. 

Under this grouping will be considered paralyses of the 
other laryngeal muscles, the result of myopathic causes. 
Most of these are infrequent, and usually are caused by 
local inflammation. If associated with constitutional af- 
fections as gout, rheumatism, plumbism, etc., they are 



Paralysis of Individual Muscles. ' 497 

usually induced by overuse of the voice or exposure, ag- 
gravating the local manifestation of the systemic condition. 

Paralysis of the Central Adductors (Arytenoids). 
— The arytenoids only may be affected, or the cricothyroids 
may also be implicated when the superior laryngeal nerve is 
involved. Paralysis of the central adductors may result 
from any chronic laryngeal inflammation, diphtheria, hys- 
teria, incipient phthisis, or any severe illness. Hoarseness 
and a rapidly tired sensation on the use of the voice, or 
aphonia, are the symptoms resulting from the partial closure 
of the glottis. The laryngoscopic picture is characteristic, 
showing accurate closure of the anterior two-thirds of the 
cords, and a triangular space from this point to the vocal 
processes at the apex, in attempts at phonation. 

Paralysis of thf Internal Tensors (Thyroaryte- 
noids). — This is the most frequent form of paralysis of 
the cords, on account of the anatomical relations. It may 
be bilateral or unilateral. Excessive use of the voice when 
there is laryngeal inflammation, fatigue, or strain of the 
muscles, diphtheria, or hysteria, are the most frequent 
causes. Change of voice consists of diminished range and 
less strength. In severe cases, whispering only may be pos- 
sible. The laryngoscopic image reveals an elliptical space 
extending the entire length of the cords, through the bulg- 
ing upward before the air current. 

Bilateral Paralysis oe Adductors (Lateral crico- 
arytenoids). — Hysterical aphonia is usually described un- 
der this title, but is really a paresis. Bosworth says a gen- 
uine myopathic paralysis of these muscles may result from 
any of the exanthemata, diphtheria, exposure to cold or 
plumbism. The laryngoscopic picture is practically im- 
possible to differentiate from bilateral paralysis of the re- 
current laryngeal nerve. 

Unilateral Adductor Paralysis (Lateral crico- 
arytenoid). — This is very infrequent, and extremely diffi- 
3 2 



498 



Nose, Throat and Ear. 





t) 


a 


a 


aS 


a 




a 


a 


> 




^ 


>> 


F»"r! 


f>> 




p^ 


>> 


►3 


>i 


)H 


u 


i— i 3 i-j 


i- 




Ih 


Ih 


04 


V- 


c<) 


TO 


TO 




TO 


TO 


0. 


a! 


tf 


4 


hT 




I-* 


M* 




►4 


+j 


„j 


^<oS 


+J 




■M 


H-> 




w 


a 


a 


a oo 


a 




a 


a 


W 


o 


<u 


u 


<u a 


V 




u 


i> 


> 




Ih . 


u . 


u . r 






<H • 


u • 


5 

w 

ft 


"C *-« 


"T3 




uri 




u — ■ 


Ih *-' 


3 bo 


3 TO 

5 ft 


3 TO 

v bo 


a to |r 

« ft5 

D 00m 


3 TO 

ai bo 




3 « 

Sft 

t> bo 


3 TO 

K bo 




CO 


to 


to 


to 


to 




to 


to 




t- 


i>TO.- 


u 


oo 


•- oi i»"IJ 


6 


jj 


I- o: u 




a; 


-1 


U . 


(LI li TO 




o 


TO 0) TO 





X . 

W j2 


H 2 

TO U 
H?0 




^ 

^ 


to 


H n — 


H 
(J 

to 


.2 o 

J U 

of" 
§1 


1^2 

TO O of *J 

•a <->!: i» 


. o 

c a 
22 

"to « 

o 2 


8| 

.^"0 

TO _ 

a ca 

o U 


d c « «i3 
S y a no 

-M *• 1> 03 J? nj 

to J? ^ r Ov2-i' 


o 

01 

Oi 

U 

0.2 


O O 3 

■C cs.2 

r- 8 Ih 3 




A a 


w-O o O 


3* 


&+* 


,gaa^ 


J <U TO 


n *• 


5 >>o >> 




to 


to 


to 


to 


to 


Q 


o 






O *> 


>> 




0) 


o 


0) 


j, 






otf 


•-< 

TO 




•d 


CJ 


o 


05 

w 


!2 


'^-H 


6 




o 

a 


^ 0) 


o 


to 


h5 

a 
en 




o 

i- 
>> 
,s 
o 

u 


So 
^ o y 
o c*C 
•r u o 

S«2 


TO+ J 


0) 

'3 
a 
u 


6 

. J3 


na 

11 >1 


"Si 
6 

u 

^5 


V 
6 




O 


to 


4 . 


•si 


H 


CO 


H 


<J^ 


<< 


> s 


• 41 bO 

aJ B 

o >is 

.> 1> IB 

« ««> « 

t-l Oi 

.-5 .. « 


lis 

Z< 55 

U o 
> a. 

o .° 

TO.^U 


TO X (J) 3 

SJiK'to 

■S « a 
.5 to - M • 
Z v 2 


a « 

•a <u 

3 ^ 

kt3 








U 


flOfl 


rt'.H'd TO 


i! ^^ to 

0)<*i"S 

>>o a 


a d = d - :£ 
,§B Q.Z to 


i ^ 












£c0 OTJ 












3 


a 


X 


O 


o 










og o^j 


o n a 


35 B 

o o 


^•^2 


C^'bO 

TO i; rj 










C< W rl V 

«^ G " . 
fl tS iu tow 


oJ'C 

a^ >> 


to-2 

.§1 

u o 
o.a 


^3§ 

■nog- 

K TO 
"J 1) u 

«- in ho 
§£.5 


»- U - 

<u o 

• IH TO U 

^to 








o 

H 

a, 


V a . w 

TO *- rt u o 


tnCO^ 

a . to d 

Si's 3 

• a tow 


+j to 

SIS 


•a o-~ - a 








> 


p 


W 


5 _^ 








CO 


C^h^2 o to 






V_- Y— i 












u 

X. ° 


1-.' 




«3"5 ° 












.Q+J 


13 +j 


>% - a 


£ TO 0) 










•{■eoSufavi 


<z 




Be 


c a a 

M W 










jouadns 


T3 


< 












* 








o^a"™ 

5 TO U 


Si i ■ 

- 8 f 


ci 






























W > *j-*- o 


rt 














n u a ii-s 


<u a <u to 


^3 














u u <u a „, 
to SO to.-, 


£2toS 


TO 














li 

02 

a 


too) 


'N 














TO 


>»o 


pb'n 














u 


CO-M 
















•^BaSaXjBl 


luajano^^ 







Paralysis of Individual Muscles. 499 

cult to diagnosticate. It may result from the same causes 
as already mentioned, and is characterized by impaired ac- 
tion or complete inability to phonate. During the attempt 
to phonate, the affected cord is firmly drawn in complete 
abduction, the other cord passing the median line by an 
extra effort. 

Prognosis. — The prognosis of any of this classification 
depends upon the cause and length of time between the 
onset and the examination. When resulting from an acute 
infectious disease or exposure, proper treatment will soon 
effect a cure, but as near complete rest of the laryngeal 
muscles as possible, is necessary. If not observed in the 
early stages, the prognosis is less favorable, especially when 
the thyro-arytenoids are implicated. 

Treatment. — Removal of the cause when possible. Rest 
of the muscles, electricity, hygiene and such measures as 
tend to restore the general tonicity of the system. 



CHAPTER XXI. 
INTUBATION OF THE LARYNX. 

This procedure consists in introducing within the larynx 
a tube for relieving alarming dyspnea. 

Indications. — These may be classified as any obstructive 
dyspnea which threaten life, and results from occlusion of 
the larynx, excepting glottic spasm. Membranous occlu- 
sions, localized within the larynx, or invading this structure 
from above. Edema, resulting from inhalation of irritat- 
ing vapors, or the swallowing of caustic or scalding fluids ; 
the localized edema from renal or other organic lesions may 
be an indication for intubation rather than tracheotomy. 
Some slow, progressive stenoses, as in specific cicatrization, 
may be benefited by this procedure. It is best adapted to 
the years of childhood, and with similar indications is 
preferable to tracheotomy if the patient has a short, fat, 
chubby neck. 

Contraindications. — When the larynx is invaded by be- 
nign or malignant growths, especially the latter, where a 
laryngectomy is contemplated, or when a morbid process 
requires absolute rest of functional activity. Also in cases 
where the obstruction is reasonably certain to be below the 
lower end of the tube. During spasm of the glottis, ex- 
cepting when remissions occur which will allow of the 
introduction of the tubes. When undue force is necessary 
to introduce the tube. 

Instruments. — O'Dwyer's set is most generally used, 
and consists of the introducing instrument, extractor, as- 
sorted tubes, gauge and mouth gag. There should be car- 

500 



INTUBATION OF THE IyARYNX. 



50I 



ried in addition to this strong fine braided ligature silk. A 
description of the instruments is unnecessary. 

Position of the Patient and Physician. — Usually the pa- 
tient is held in an upright position by an assistant, the 
arms being confined by wrapping a sheet around the little 
one. In this way the child is held steadily by the assistant's 
grasp around the body and arms, the lower extremities be- 
ing held between the knees. Another assistant stands be- 
hind the patient and steadies the head and makes vertical 
extension of the neck. The gag is placed in position be- 
tween the molars on the left side, the physician introducing 




Fig. 100. Showing position of tube and finger in intubation. 



the index finger of the left hand into the mouth, following 
the median line to the epiglottis, which is then raised and 
steadied by a slight lateral pressure. The tube in position on 
the introducer is passed back in the median line, using both 
the index finger and the eye as guides, and keeping the 
handle of the introducer depressed, until the end of the tube 
reaches the finger tip, then raising the handle, carefully 
introduce the tip of the tube into the larynx, guiding its 
passage with the index finger. When the tube is in place, 
release the obturator and withdraw the instrument, keeping 
the tube in place with the finger. After the tube is released, 



502 Nose, Throat and Ear. 

the silk loop is fastened around the patient's ear or around 
the neck. 

Kyle's method is to wrap the patient tightly in a sheet, 
confining the arms to the body, and placing the patient on 
its back on a table, allowing the head to hang over the edge 
which causes extension of the anterior structures of the 
neck. An assistant stands on one side and by leaning over 
holds the patient firmly by the pressure of the shoulders, 
and prevents lateral movements by extending the arms at 
the sides, steadying at the same time the patient's head with 
the hands. The physician sits opposite the patient's face 
and introduces the gag with the handle turned away from 
him, and opens the jaws to their full extent. A second as- 
sistant, using a soft cloth, grasps the tongue and draws it 
forward. The index finger of the left hand is then intro- 
duced and the epiglottis lifted and steadied. The tube is 
then introduced, the same positions being observed as in the 
upright position, the right arm is extended and curved, and 
the tube readily carried along the median line to the larynx. 
The rest of the manipulation is identically the same as al- 
ready described. Before attempting to introduce the tube, 
the easy movement of the silk loop should be determined, 
as well as freedom of release of the tube from the obturator. 

Accidents, Complications, and Dangers. — It must be re- 
membered that operative procedures involving the respira- 
tory tract are more difficult of performance than a descrip- 
tion would indicate. The struggles and gagging of the pa- 
tient, no matter how firmly held, will make the handling of 
instruments difficult. The gag may become disarranged, 
and unless the operator's finger is protected by a metal 
guard, it may be severely lacerated by the patient's teeth. 
Secretion may be forcibly expelled during a coughing 
paroxysm, and strike the physician in the eye, nose, or 
mouth, thus causing infection. The tube may not be the 
proper size, if too large it can not be introduced, and if 



Intubation of the Larynx. 503 

too small it may pass between the vocal cords into the 
trachea. The direction of the tube in introducing it, may 
be faulty, and it will pass into the esophagus. The tube 
may push membrane before it, occluding the tube and 
trachea, necessitating immediate tracheotomy. Sometimes 
the tube will become rilled with shredded membrane or 
tough secretions, necessitating removal and cleansing. Glot- 
tic spasm may be so severe that it is impossible*to introduce 
the tube. There should be considerable relief after the 
tube is introduced, if there is not, a careful examination as 
to the cause should be made. An undue amount of force 
should not be made in trying to introduce the tube, and not 
infrequently several attempts will be necessary. It is essen- 
tial that the thread be not forgotten, as the tube can usually 
be quickly removed, and if it has been wrongly placed, 
there is not the danger of the patient swallowing it. 

Post-operative Care. — From the time of the introduction 
cf the tube until its removal, the case must be carefully 
watched. In membranous conditions the lumen of the tube 
may be suddenly closed. Closure of the tube may also occur 
in cases having an excessive amount of tough, tenacious 
secretion. In either case the tube must be immediately re- 
moved and cleansed. It is important that the nurse be in- 
structed regarding the symptoms necessitating the removal 
of the tube, and also how to remove it by means of the 
thread. If necessary to remove, and the tube seems to be 
held firmly in position, the patient should be inverted, and 
the back and chest sharply slapped, this method will usually 
dislodge the tube. Occasionally the tube may be displaced 
during a paroxysm of coughing, when often it will be found 
unnecessary to replace it. Sometimes the thread will break, 
and the tube be dislodged and swallowed, but no untoward 
results follow this accident. 

The feeding of the patient is often a difficult problem. 
Some, after a few efforts, will be able to take liquids, and 



504 Nose, Throat and Eak. 

others semi-fluids. In some cases with the head lower than 
the body, fluids can be taken from a nursing bottle. The 
stomach tube may be required, and even rectal feeding. If 
nutrition is much impaired, it may necessitate tracheotomy. 
In the removal of the tube, if the thread has become de- 
tached, the method of procedure is practically the same as 
for intubation, but the extractor is used instead of the in- 
tubator. 

, Sequela. — After the tube has been worn for a time, a 
paresis of the vocal cords usually occurs, but passes off after 
a time. Erosion of the cartilages has been reported in a 
few cases. 



CHAPTER XXII. 
TRACHEOTOMY, ETC. 

This means an incision of the trachea, and the mainte- 
nance of an artificial opening more or less permanent, by 
artificial means. 

Similar operations involving the larynx are designated, 
according to location, laryngotomy, thyrotomy, thyroidot- 
omy, etc. , 

Indications. — Occlusion of the larynx by membranous 
formation in croup or diphtheria, especially when the soft 
tissues of the chest recede in inspiration, unless intubation 
affords considerable relief, tracheotomy is required. In 
edema of the glottis and periglottic tissues, and also in some 
cases of injury at the base of the tongue the pharynx, or 
laryngeal fractures, a tracheotomy may be necessary. Se- 
vere dyspnea resulting from protracted spasmodic action of 
the laryngeal structures may also be an indication. The 
operation may also be indicated in some cases of tubercular 
laryngitis, in the progressive stenosis of syphilis or obstruct- 
ive gummata. Laryngeal growths, the pressure exerted by 
inoperable malignant disease, or foreign bodies in the air 
passages, which can not be removed through the pharynx, 
may necessitate this operation. 

C ontra-indications. — Whenever the chances are that in- 
tubation will afford relief, tracheotomy should not be per- 
formed. 

Operative Procedures. — The patient should be lying flat 
on the back, with a pad under the neck which causes full 
extension of the head, and the structures of the anterior 
structures of the neck be made prominent, tense, and firm. 

505 



506 Nose, Throat and Ear. 

Unless contra-indicated, general anesthesia is preferable, 
but when not advisable to use general anesthesia, the use 
of ethyl chloride will suffice, as there is little pain after the 
integument is divided. When local anesthesia is employed, 
an assistant must steady the head. The hypodermatic use 
of cocaine, etc., is not advisable. The skin of the neck 
should be properly cleansed before making the incision. 

The physician should have a small scalpel, grooved di- 
rector, small retractors, blunt hooks or aneurism needles, 
tenaculum, hemostats, dissecting forceps, a sharp pointed 
bistoury for opening the trachea, and a probe pointed bis- 
toury for enlarging the incision if required; tracheotomy 
tubes, tape, tracheal dilator, tracheal forceps, and such other 
appliances as are usually required in surgical procedures. 
An assortment of tracheotomy tubes should be at hand, and 
the largest that can be worn comfortably is usually the best. 

The isthmus of the thyroid gland determines the anatom- 
ical division for the various operations. High tracheotomy 
is understood as being above the level of the middle of the 
thyroid isthmus, and is most easily performed. If the in- 
cision extends upward, dividing the cricoid cartilage, it is 
called laryngotracheotomy. Low tracheotomy is where the 
incision opens the trachea below the middle of the thyroid 
isthmus, and is preferable in some cases of foreign bodies, 
jor if a permanent opening is necessary. 

High Tracheotomy. — With the patient in the proper 
position, the operator locates the landmarks, and ascertains 
if possible, the course of the anterior jugular veins. The 
tissues being steadied with one hand, the initial incision is 
made through the skin, from about the level of the cricoid 
downward in the median line an inch and a half to two 
inches. If any veins present, they should be pushed to one 
side or ligated and divided. The grooved director is pushed 
under the superficial fascia which is then divided, and the 
deep fascia exposed. The same procedure is employed in 



Tracheotomy, Etc. 507 

dividing the fascia and the incision of both must be the same 
as the initial cut. If any veins are encountered in this deep 
layer, they should also be pushed aside or ligated and cut. 
The intermuscular space between the sternohyoids and 
sternothyroids is determined and opened with a blunt dis- 
sector. The blunt retractors should be used to keep the cut 
surfaces separated, and an equal amount of force used on 
each, avoiding downward pressure, either of which might 
cause a displacement of the trachea. The bottom of the 
opening should be a layer of the deep cervical fascia, which 
divides in this region to surround the thyroid isthmus, and 
some of this latter structure may be outlined, or be bulging 
into the wound. The grooved director should be used, as 
on the other fascias, and after the incision is made, the isth- 
mus of the thyroid is drawn downward by a blunt hook. 
If the isthmus occupies too much of the wound, a trans- 
verse incision, not over half an inch, may be made over the 
cricoid, and the fascia and isthmus together be stripped up 
and drawn downward. The loose connective tissue over- 
lying the trachea must be carefully cleared from the operat- 
ive field to expose the rings of the trachea. A tenaculum 
is fastened to the cricoid cartilage, steadying the larynx and 
trachea, and guarding the knife with the forefinger, to pre- 
vent cutting too deeply, the blade is introduced into the 
trachea in the median line above the isthmus and cutting 
upward, divide two or three of the tracheal rings. When 
there is membrane in the trachea, it should be incised, as 
otherwise it may be pushed downward by the knife. After 
the trachea -is opened, there is often coughing and ejection 
of bloody mucus, etc. Not infrequently there is an alarm- 
ing collapse of the patient after the trachea is opened. The 
trachea should be cleared as much as possible of morbid 
material, the traumatic surfaces cleansed, and the tube in- 
serted and retained in position by tapes passed around the 
neck. Sutures may be used below the tube. If tubes are 



508 Nose, Throat and Ear. 

not used, the opening may be preserved by the use of blunt 
retractors held in position by tape or elastic bands. 

Low Tracheotomy. — This operation is performed prac- 
tically the same as the high. The initial incision extends 
from just below the cricoid cartilage nearly to the manu- 
brium. The fascia are divided as in the high* operation, 
but the thyroid isthmus is drawn upward. In this operation 
the thyroidea ima artery must be remembered as well as an 
occasional unusual height of the innominate artery as far 
as the eighth or seventh ring of the trachea. The size of 
the thymus gland should also be remembered, it being in 
inverse ratio to the age of the patient. The rest of the 
operation is similar to that of a high tracheotomy. 

Laryngotomy. — This is probably the easiest and quick- 
est operation in an emergency case on account of the super- 
ficial position of the cricothyroid membrane and the lack of 
important vascular structures, but should not be performed 
on a patient under thirteen years old on account of the small 
size of the cricothyroid space. The membranous space be- 
tween the cricoid and thyroid is determined and a median 
incision through the skin and fascia is made. The sterno- 
hyoid and sternothyroid muscles are separated and a trans- 
verse cut is made through the cricothyroid membrane close 
to the border of the cricoid. The small cricothyroid artery 
is to be avoided. The knife is to be guarded with the finger 
as in tracheotomy. A short tube may be inserted or re- 
tractors used to keep the wound open. If the operation 
has been performed as an emergency measure, and it is un- 
necessary to keep the wound open, it may be allowed to 
heal by granulation. 

Operative Complications and Dangers. — Opening into 
the larynx is not normally a difficult operation, but when 
the necessity for operative measures are present, an ab- 
normal condition exists, which complicates the work. Un- 
due haste is usually unnecessary, but in some instances a 



Tracheotomy, Etc. 509 

prompt thrust with the knife may be required, simply locat- 
ing the prominent points by a rapid examination, in order 
to preserve life. The rapid movements of the larynx and 
trachea in labored inspiratory efforts, makes the work diffi- 
cult. In these cases there is nearly always considerable en- 
gorgement of the veins, and profuse hemorrhage is liable 
to occur, but this often rapidly diminishes after respiration 
is restored. An accidental cut of the thyroid isthmus may 
be followed by a sudden and profuse hemorrhage, requiring 
an immediate use of hemostatic forceps. A faulty position 
of the retractors or a deviation from position, may result 
in a dangerous lateral incision reaching even to the verte- 
brae. Excessive pressure of the retractors against the 
trachea may contuse the structures. If membrane is pres- 
ent in the trachea, the knife may push it backward instead 
of penetrating it, thus giving no relief from the dyspnea, 
or even aggravating it by crowding the membrane into a 
compact mass in the trachea. In the latter complication the 
use of tracheal forceps, scissors, or knife may be promptly 
required. Occasionally the knife may injure or penetrate 
the posterior tracheal wall and even incise the esophagus. 
The trachea may be obstructed with blood, blood and mucus, 
or mucus, which will have t© be removed. In these cases the 
Trendelenburg position, or partial inversion will aid in ex- 
pelling the material, keeping the wound open to aid in its 
expulsion. A flexible catheter may be used to aspirate the 
material and to force air into the trachea, introducing it 
far enough so the air enters the lungs. The respiration 
may suddenly cease, either prior to or following the com- 
plete incision. If the former, the operation must be im- 
mediately completed and efforts made to restore respira- 
tion, the usual methods being employed. As a rule the 
collapse is transitory. 

Post-operative Care, Dangers, and Complications. — The 
after attention is equally as important as the skill in per- 



510 Nose, Throat and Ear. 

forming the operation. If the measure is simply for the 
removal of a foreign body, a thorough cleansing of the 
wound with an antiseptic solution and covering with a 
sterile dressing will be all that is required, the wound heal- 
ing by granulation. If an edematous condition is feared, or 
for any other reason it is desirable to wait a short time be- 
fore allowing the - losure of the wound, a tube or retractors 
may be used. Verat-um or aconite is usually required, and 
cough should be controlled by the indicated remedy. The 
patient should be kept in the recumbent position, the air in 
the room warm, and kept moist by boiling water, or moist 
gauze may be placed over the tube or opening. It is not: 
often -necessary to resort to artificial methods of feeding. 
Careful attention to the usual body functions is necessary 
and as much rest and sleep as possible insisted upon. When 
a tube is to be retained, the patient will require close at- 
tention, especially while recovering from the anesthetic, 
and also later on in young children. The moistened gauze 
should be used, as it clears the inspired air of dust. It is 
essential that the tube should be kept free of accumulations 
of mucus, etc., and this will necessitate considerable care in 
many cases. In conditions where there is a rapid accumula- 
tion of secretion, it may be necessary to cleanse the tube 
every half hour, a feather or brush being used for the 
purpose. The inner tube may have to be removed on ac- 
count of becoming occluded with membrane. The canula 
must also be cleansed with an alkaline solution, but the in- 
ner tube should not be left out too long. In membranous 
cases, the occlusion may require the removal of the canula, 
and the tracheal dilator and forceps be needed for remov- 
ing the material. Directions for the removal of the canula 
the membrane, and for keeping the wound patent until the 
physician arrives, should be given, as until sufficient heal- 
ing has occurred to form a canal, the reintroduction of the 
tube is often difficult. The canula should be removed 



Tracheotomy, Etc. 511 

every two or three days, and if any discoloration from 
sloughing areas is observed, such areas should be touched 
with nitrate of silver, the surfaces cleansed and after cleans- 
ing the tube it should be replaced. In membranous cases 
the tube is required for from eight to fifteen days, but the 
time varies according to the case. When the tube is per- 
manently removed, the wound heals by granulation. 



CHAPTER XXIII. 
EAR. 

Malformations. 

Congenital malformations may be divided- into four 
classes : ( i ) Deformity of some portion of the auricle, but 
the general contour of the external ear not changed. (2) 
Change in contour or a malposition of the auricle. (3) An 
anomalous condition as supernumerary appendages, fistulae, 
etc. (4) Asymmetry of the auricles. 

(1) Helix. — The so-called Darwinian and satyr ears 
are not uncommon. The absence of the upper portion of 
the helix has been reported, as well as an abnormal develop- 
ment of this part. 

Antihelix. — This may be developed so as to project be- 
yond the line of the helix. This condition seems to be found 
more frequently in the criminal classes or the insane. In- 
frequently there is such a development of the superior crus 
of the antihelix as to crowd the helix upward and forward, 
(producing the so-called pointed ear. 

Lobule. — In the colored race the lobule is often ex- 
cessively developed. The lobule may be absent or rudi- 
mentary. Cleft lobule is probably oftenest found. 

Tragus. — This may extend so far backward as to ac- 
tually interfere with sound waves entering the meatus. 

Antitragiis. — Very seldom found. In one case reported, 
two cartilaginous spurs projected from the antitragus into 
the canal. 

(2) Change: in Contour or a Malposition of the 
AuriciX — The most notable form is termed microtia, and 

512 



Malformations. 513 

results from an arrested or perverted development, the dis- 
tinctive parts of the auricle being illy defined. One or both 
sides may be affected, and often there is some deformity 
of the deeper portion of the ear. As a rule the external 
auditory meatus is lacking or rudimentary. The ossicles 
may be absent or non-developed, and the labyrinth is also 
often defective. To relieve the external appearance a plastic 
operation may be beneficial when the deformity is not very 
extensive, but trying to form an artificial meatus is usually 
an unsatisfactory procedure. 

Another anomaly is where the auricle stands out from 
the head at considerable of an angle. In early childhood an 
improvement may be obtained in some cases by such meas- 
ures as will draw the auricle closer to the head and retain 
it in the desired position. Collodion or adhesive plaster 
may be employed for the purpose. Strips of gauze may also 
be employed to press the auricle to its, normal position. The 
mechanical treatment must be continued for some time. 
In adults, operative measures are necessary. 

(3). Anomalous Conditions as Supernumerary Ap- 
pendages, FlSTUL/E, ETC. 

Auricular Appendages, the General Contour of the Auri- 
cle Normal. — The usual location is the region of the tragus, 
and sometimes these appendages are quite large. The re- 
moval of these anomalous growths is usually easy. 

Included under this division is "fistula congenita auris." 
This is the result of defective development and is not very 
often seen. The defect may or may not be bilateral. The 
fistula may be located immediately above the tragus, or con- 
siderably higher. A slight discharge may come from this 
tract. Unless a retention cyst forms, no treatment is re- 
quired. If a cyst forms occluding the opening of the sinus, 
an incision and removal of the contents, then curetting the 
walls of the cyst is necessary. 

Polyotia. — This means, besides microtia, supernumer^ 
33 



514 Nose, Throat and Ear. 

ary growths in the neighborhood of, but distinct from the 
auricle, and may be only on one side. These growths some- 
times are present with a normal auricle. They vary in shape 
and size, but usually are wart-like. These growths are 
usually readily removed, although a plastic operation may 
be required. 



CHAPTER XXIV. 

WOUNDS, INJURIES, CUTANEOUS 

AND INFLAMMATORY DISEASES 

OF THE AURICLE. 

Wounds of this structure are infrequent, but more or 
less severe injury from burns are not uncommon. In lacer- 
ated wounds, if seen early, the approximation of the sur- 
faces by adhesive strips, collodion or sutures, which should 
be introduced on the posterior surface, will usually give 
satisfactory results. If the injury is of long standing, plas- 
tic work is necessary. On account of the large proportion 
of cartilage in the auricle, perichondritis is liable to follow 
much bruising of this structure. 

Contusion is a not infrequent condition, and hematoma 
or perichondritis may result, and it is not always easy to 
differentiate between them in the early stages. There is a 
spherical tumefaction, which on palpation reveals fluid. The 
color of the swelling varies, depending upon the character 
of the injury, and somewhat upon the nature of the fluid. 
If blood, the appearance is usually a dull deep-red color, 
but in perichondritis with an effusion of serum, the color 
may be much lighter, or even no change from the normal. 
Either condition may remain passive for some time ; or it 
may disappear spontaneously leaving more or less deform- 
ity; or suppuration and evacuation of the material may 
result. 

When extravasation of blood has occurred from an in- 
jury, the cartilaginous tissue has usually been injured, ne- 
crosis and exfoliation nearly always following, resulting in 

5i5 



516 Nose, Throat and Ear. 

deformity. In simple perichondritis deformity is less liable 
to occur. 

In burns, not only the integument, but often the deeper 
structures are injured, and sloughing of the parts may 
occur. A perichondritis or chondritis is not infrequent in 
these cases, and the resulting deformity may be considerable, 
sometimes nearly the entire auricle being destroyed. 

Treatment. — In perichondritis from contusion, if seen 
early, the application of cold by the use of an ice-bag or 
Leiter's coil, or better still, a cold dressing of aconite and 
veratrum aa 3j, to aqua §iv, will often prevent much ef- 
fusion. Evaporating lotions may be used for the same 
purpose. When effusion has occurred, the most satisfactory 
results are obtained by a free incision, then curetting the 
sac walls and packing with gauze, endeavoring to have the 
space fill by granulation. Often healing will occur in these 
cases without much deformity. If necrotic changes have 
occurred, the same procedure is required, all softened areas 
being curetted, and the after treatment as designated above. 

In burns or scalds, the treatment will not vary mate- 
rially from that already given, only such measures should 
be employed as will relieve the pain, and for this purpose a 
10 per cent aristol ointment has been of value. 

When the ears have been frozen, the usual application 
of snow, or pounded ice, followed by cold water is the best 
first aid. The after treatment will not vary materially from 
what has already been given. 

Internally aconite, veratrum, and lime in some form 
are usually required. 

In any of these conditions the blood supply must be con- 
sidered, and the strapping or binding of the auricles to 
the head, or any undue pressure upon them, or at their at- 
tachment, is to be avoided. Extensive loss of tissue or con- 
siderable deformity is liable to follow unless free circula- 
tion is maintained. 



Eczema. 51? 

Intertrigo. 

This condition is most frequently found in young chil- 
dren, especially among those who are compelled to wear 
the "cute" caps which press the auricles close to the sides 
of the head. When this is continued for some time, the ac- 
tion of the body temperature and moisture causes desquama- 
tion of the superficial epithelium, exposing the deeper layer 
of the integument to the air. Hypersecretion from the de- 
nuded areas increases the condition, and the intense itch- 
ing causes the child to still further irritate the parts. The 
posterior surface of the auricle and the corresponding area 
of the side of the head, presents a reddened appearance, and 
an abundance of serum covers the denuded parts. The tis- 
sue of the affected area is not thickened, which differen- 
tiates the condition from eczema, but the latter soon fol- 
lows if relief is not promptly given. Illy nourished chil- 
dren appear most susceptible, and hereditary predisposition 
to skin affections also seems to have an influence in produc- 
ing this condition. Lack of cleanliness is also an undoubted 
factor. 

Treatment. — Separation of the denuded surfaces, and a 
covering by some of the dusting or toilet powders is all that 
is required as a rule. Cleansing of the parts with an un- 
irritating soap, and in some cases the use of an ointment of 
Eucalyptus, will also be necessary. 

Eczema. 

This may be either acute or chronic in character. 

Etiology. — The causes are not well understood. Hered- 
itary predisposition, as a gouty or rheumatic tendency, or 
scrofula, may have an influence, while disturbances of the 
alimentary canal, improper food, etc., are often followed 
by this condition. 

Local causes are important factors, as the discharge 



51S Nose, Throat and Ear, 

from a suppurating otitis media, if long continued, is very 
liable to cause eczema. Lack of cleanliness may also pro- 
duce this condition, especially where there is a predisposi- 
tion to skin affections. 

Symptoms. — In acute attacks there is often a sensation 
of burning or discomfort at some part of the auricle. In 
children, this is usually at or near the junction of the ear 
with the side of the head, but it may affect any portion of 
the auricle. An intense pruritus soon follows, and the 
scratching of the parts increases the irritation.' The surface 
is reddened and desquamation of the superficial epithelial 
layer soon occurs ; a moist serum exudate covering the sur- 
face, or later crusts, which on their removal reveal bright 
red surfaces. A vesicular form may be present, the vesi- 
cles soon becoming pustular and rupture, covering the sur- 
face with thick, dirty, yellowish crusts, a slight hemorrhage 
often following their removal. 

In the chronic type a part of, or the entire auricle may 
be affected. It is characterized by either a dull pinkish 
color, the surface being glossy as though the skin was thin 
and tense, or as though the superficial epithelium was ex- 
foliated too rapidly, the surface being irregularly covered 
with fine, whitish scales or crusts. The intense itching 
causes the patient to pick off these scales, and often abrasion 
of the skin follows these efforts, which augments the con- 
dition. The unabraided surface has a smooth feel to the 
touch. 

Pathology. — In both forms there are true inflammatory 
changes in the deeper layers of the integument, which do 
not vary particularly from those of mucous membranes. 
Palpation reveals the thickened condition of the parts, show- 
ing that an infiltration has occurred. 

Diagnosis. — Attention to the symptoms usually renders 
the diagnosis easy. 

Treatment. — This necessarily is directed to the exciting 



•Herpes. 5 x 9 

cause, whether local or systemic. The administration of 
arsenic in some form in chronic conditions, is usually bene- 
ficial. Saline cathartics are also often required. Podophyl- 
lum, chionanthus, nux, rhus tox., or hydrastis may be in- 
dicated. The local use of salicylic acid ointment in the 
dry, scaly form, will usually afford relief and hasten a cure. 
In the moist form the ointment of eucalyptus, or the stearate 
of zinc comp. with europhen or tar will often be most grate- 
ful to the patient. Liquid preparations, and frequent bath- 
ing of the parts usually increase the trouble. Protection 
from the air is especially important in the moist forms. 

Pemphigus. 

This is an infrequent condition, but resembles the same 
lesion upon other parts of the body. The etiology is un- 
known. The affection appears in the form of bullae which 
are filled with a clear serous fluid, and the blebs are usually 
located on the margin of the helix and lobule. The fluid 
may become turbid but seldom is purulent. After a few 
days spontaneous rupture occurs, the surface eventually 
showing simply a slight redness, or an eroded condition de- 
pending upon whether the sac walls are destroyed or not. 
When the surface is eroded, there will soon followed a dry- 
ness of the area, and a reddened condition will persist for 
some time. Pain is absent, but recurrence is the rule. 

Treatment. — Puncture the blebs,* and cover the surface 
with flexible collodion. Internally such remedies as are in- 
dicated. ♦ 

Herpes. 

Infrequently seen. It resembles herpes zoster, modified 
only by its location. Found most frequently in neurotic 
subjects. 

Etiology. — Faulty nutrition and improper food are often 
considered factors. As an exciting cause, exposure to cold 
is often credited, as having a direct influence. 



52b Nose, Throat and Ear. 

Pathology. — Not understood, but is probably a neuritis 
of the trophic nerves. 

Symptoms. — Usually ushered in by severe systemic 
symptoms. The pulse is rapid, temperature increased, 
varying from ioo° to 103 ° Fah., headache and general 
malaise. Neuralgic pain, confined to the ear, or over the 
entire side of the face supplied by the affected nerve. The 
pain may precede the eruption. When the eruption occurs, 
vesicles filled with serum cover the affected area, the bases 
being reddened. If coalescence occurs, a bullous type 
results. . The outer surface of the auricle is usually affected, 
and it usually is unilateral. The affection may invade the 
external auditory canal. The vesicles 'rupture in a few 
days, and the secretion dries and forms small scales which 
loosen and leave a reddened or brownish colored surface. 
In cachectic patients, a superficial ulceration may continue 
for some time. After the eruption the systemic symptoms 
usually subside. Frequently there are recurrent attacks. 

Diagnosis. — Easy after the appearance of the vesicles, 
but prior to this, it is often difficult. 

Treatment. — The constitutional treatment should be di- 
rected to cleansing the alimentary tract, and the saline ca- 
thartics are usually indicated. The food should be such as 
produces the least amount of waste products, being nutri- 
tious and easily assimilated. For the febrile symptoms, 
aconite or veratrum. Rhus tox. is often indicated in these 
cases. Phytolacca is frequently required on account of its 
action on the glands. 

Locally. — Cold applications are often useful before the 
eruption appears, but after the vesicles form, some unir- 
ritating dusting powder should be used. 

Syphilis. 

Any form of syphilis may appear on the auricle, but is 
infrequently seen. The appearances are similar to those 
found elsewhere, and the treatment is the same. 



Inflammatory Conditions. 521 

Lupus Erythematosus. 

Usually secondary, as the condition spreads from some 
other portion of the face. 

Etiology. — All forms of lupus are now considered tuber- 
cular. 

Symptoms. — In the early stages, circumscribed, slightly 
elevated areas are noticed, which soon extend in all direc- 
tions. The skin over these areas is thickened, injected and 
separated from the normal cutis by a decided line of de- 
marcation. A glazed appearance is noticed, owing to the 
retarded blood supply. The general progress is similar to 
that on the face. Very infrequently both sides are affected. 

Treatment. — The same as for this condition on the face. 

Lupus Vulgaris. 

Very seldom seen as a primary condition. It should be 
treated the same as when occurring upon the face. 

Inflammatory Conditions. 

Perichondritis. 

This sometimes occurs as an idiopathic condition, or as 
a complication of acute inflammatory action of the external 
auditory canal. 

Symptoms. — A sensation of heat, which is soon followed 
by pain. The auricle swells, and the skin over the affected 
area becomes a bright red. The swelling may increase un- 
til the outline of the auricle is lost, as a result of the effusion 
of serum between the cartilage and perichondrium. This 
fluid soon becomes purulent. The portion and extent of the 
tissue involved determines the amount of deformity. Un- 
less relief is obtained by proper treatment, spontaneous rup- 
ture will occur, leaving sinuses which are difficult to heal, 
and usually considerable deformity remains. 



522 Nose, Throat and Ear. 

Treatment. — Practically the same as in perichondritis 
from injuries, excepting that aspiration is not beneficial. 
Gruening advises incisions passing from before backward ; 
penetrating the entire structure and keeping the incisions 
open by means of gauze. If the tragus is the part affected, 
Dench recommends a free incision and curetting of the 
cavity. The internal treatment should be as indicated. 

Erysipexas. 

This is practically always secondary to facial erysipelas, 
and the treatment is the same. 

Abscess. 

Usually an abscess is the result of a perichondritis, but 
occasionally a circumscribed collection of pus may occur 
in the portion of the auricle composed of fatty and fibrous 
tissue. It nearly always is due to local infection, the lobule 
being usually the site, through irritation from an earring or 
piercing the ears. Infrequently a superficial abscess is lo- 
cated elsewhere in the auricle without implicating the car- 
tilaginous structure. This condition is a retention cyst, 
caused by the closure of the orifice of a sebaceous gland. 

Treatment. — Evacuation of the abscess and curetting 
the sac walls is usually all that is required. 

Hematoma Auris. 

Synonym. — Othematoma. 

This consists of an effusion or transudation of blood be- 
neath the perichondrium, separating this tissue from the 
cartilage. 

Etiology. — Often the result of an injury, but among the 
insane it is of comparatively frequent occurrence. It not 
infrequently is found occurring without any known cause, 
and age is not a factor. 



Inflammatory Conditions. 523 

Diagnosis. — The swelling is usually sudden, and with- 
out any premonitory symptoms, but occasionally there may 
be an initial burning or itching. The skin covering the 
swelling may be normal in color, or pale, this depending 
upon the amount of pressure exerted. The swelling usually 
involves more or less of the anterior surface. When the 
result of an injury, the history w T ill aid in making the diag- 
nosis. When not from a traumatism, the suddenness of the 
swelling will decide its character. 

Treatment. — If the swelling is small and of recent oc- 
currence, a firm compress may promote absorption, but as 
a rule evacuation is the best procedure. Aspiration followed 
by compression when the tumor is small, or a free incision 
and curettage if of considerable size, especially if a puru- 
lent condition exists. More or less deformity is liable to 
occur in severe cases. 

Thickening of the Lobule. 

This results from a chronic inflammatory action in 
which both the connective tissue elements and the glandular 
structures are hypertrophied. It is usually the result of 
mechanical irritation, most frequently from wearing ear- 
rings of cheap material. 

Treatment. — Removal of exciting cause. If the deform- 
ity is considerable, a plastic operation may be necessary. 

Ossification. 

This is of very infrequent occurrence, and but few cases 
have been reported. 

GangrFnf. 

Necrosis of the auricular tissues sometimes occurs in- 
dependent of traumatic lesions. In cases of extreme debil- 
ity, such as follow the typhoid type of disease ; or where a 



524 Nose, Throat and Ear. 

continued suppurative process with necrosis of the bony 
structures of the temporal bone have occurred, a gangren- 
ous state may occur, especially if pressure of the auricle 
against the head is continued for some time. 

Treatment. — Practically as in gangrene of other struc- 
tures. 



CHAPTER XXV. 

BENIGN AND MALIGNANT TUMORS 
OF THE AURICLE. 

Benign. (i) Angioma, (2) Atheroma,- (3) Cystoma, 
(4) Fibroma, (5) Lipoma, (6) Papilloma. 
Malignant. (1) Epithelioma, (2) Sarcoma. 

Angioma. 

Infrequently seen, and vary considerably in size. The 
condition may be single or multiple, and usually the growth 
is slow. Kipp reports a case in which freezing of the auri- 
cle was a cause, but usually it is congenital. The auricle 
may be changed in contour or position and present a 
purplish-red color. 

Treatment. — This will depend upon the size, character, 
and location. If small, electrolysis or the galvano-cautery 
will usually be sufficient. If large, extirpation may be re- 
quired. 

Atheroma. 

This is caused by a filling up of obstructed sebaceous 
follicles, the secretion being retained through closure of the 
orifices, and more or less swelling occurs through con- 
tinued secretion, and if the gland is active the pressure may 
be sufficient to cause spontaneous rupture, or some of the 
secretion may escape through the duct and partially relieve 
the condition. This may recur repeatedly, the patient com- 
plaining of intermittent discharge from the growth. Some- 
times the pressure may be severe enough to cause an in- 
flammation within the follicle, when a purulent discharge 
will result. 

525 



526 Nose, Throat and Ear. 

Location. — The lobule or the junction of the lobule with 
the neck is the favorite site, although other parts of the 
auricle may be affected. 

Treatment. — Operative. The tumor should be removed 
through a free incision, care being taken not to rupture the 
sac. If the sac is adherent, or ruptures, it should be dis- 
sected from the surrounding tissue. Curettement is usually 
necessary, and salicylic acid ointment, or thuja applied to 
the cavity. 

Cystoma. 

The term is properly applied to a swelling upon the 
auricle, the result of a circumscribed collection of fluid in- 
dependent of traumatism. Usually upon the anterior sur- 
face. The skin covering the tumefaction is normal in color 
and not sensitive to touch. The swelling occurs suddenly 
and seldom shows a tendency to increase in size. The cause 
is obscure. 

Treatment. — The most certain method of treatment is 
by an incision, so made as to leave the least possible amount 
of deformity. This is best done by cleansing the sac thor- 
oughly, closing the incision, and obtaining drainage by 
puncturing the cartilage, opening upon the posterior sur- 
face of the auricle. 

Fibroma. 

This is the most frequently found benign growth of the 
auricle. It is quite common among colored people, and' 
often is of considerable size. The irritation caused by ear- 
rings is the usual cause. The lobule is affected more than 
any other part of the auricle. The tumor is hard, and 
usually smooth, and is composed of dense, white, fibrous 
connective tissue. There is often a tendency to recurrence 
after removal, the new growths sometimes being of a ma- 
lignant type. 

Treatment. — Complete extirpation. 



Malignant Growths. 527 

Lipoma. 
These growths sometimes occur just below the lobule. 
Seldom if ever are they found on the auricle. They should 
be removed the same as lipoma of other regions. 

Papilloma. 
These in the simple form appear only as warts, and are 
easily removed. 

Malignant Growths. 

Malignant growths of the external ear are seldom pri- 
mary. They may attack any portion of the auricle or the 
external auditory canal. 

Epithelioma. 

Epithelioma of the auricle is probably due to the same 
cause as in other regions. Seldom occurs under the age of 
fifty, and the growth is usually slower than when it occurs 
elsewhere. The cervical glands are not often affected, 
hence systemic infection is infrequent. The characteristics 
of the growth are similar to those found in other regions. 

Treatment. — Radical treatment, removing the entire 
mass is the proper measure. If thoroughly performed, there 
is seldom a recurrence. 

Sarcoma. 

Sarcoma is comparatively infrequent, and may be either 
primary or secondary, any portion of the auricle may be 
affected, and the morbid process may extend to the external 
auditory canal. The appearance of the growth varies ac- 
cording to its location. It is less firm, and ulceration occurs 
later than in epithelioma. 

Treatment. — Extirpation of the growth by surgical 
measures. Recurrence is infrequent, 



CHAPTER XXVI. 

AFFECTIONS OF THE EXTERNAL 
AUDITORY CANAL. 

(i) Acute Circumscribed External Otitis. (2) Chronic 
Circumscribed External Otitis. (3) Chronic Diffuse Ex- 
ternal Otitis.. (4) Acute Diffuse External Otitis. (5) 
Croupous and Diphtheritic External Otitis. (6) Hemor- 
rhagic External Otitis. (7) Impacted Cerumen. 

Acute Circumscribed External Otitis. 

Circumscribed External Otitis; Otitis Externa Circum- 
scripta acuta; Furuncle; Boils. 

Etiology. — This condition may result from mechanical 
irritation, as introducing aurilaves, hairpins, etc., to re- 
lieve an itching sensation ; to inoculation by the same 
means ; denudation of the epithelium from mechanical 
causes or cutaneous disease ; or from the irritation caused 
by a suppurative disease of the middle ear. In some cases 
no cause can be determined. 

Pathology. — The fibrocartilaginous portion of the canal 
is most frequently affected, the favorite location being the 
inferior, posterior, or superior walls. The swelling is 
usually near the external opening, but may be in any por- 
tion of the canal. The disposition to occur in crops is very 
marked. Whether a specific germ is responsible is a ques- 
tion, but that the suppurative process is often of a reflex 
character is very probable. The inflammatory process may 
extend to the perichondrium, and even the auricle, tym- 

528 



Acute; Circumscribed External Otitis. 529 

panum, or mastoid cells may be implicated. The suppura- 
tive process is similar to furuncles in other regions. 

Symptoms. — Generally the first indication is a sense of 
fullness, discomfort, or itching. In a short time tender- 
ness or pain becomes marked. The hearing is impaired, and 
tinnitus is often very annoying. The pain rapidly increases 
in severity, often producing hysteria in nervous patients. 
Pressure in front of the tragus increases the pain, and mo- 
tion of the lower maxillary may be so painful that mastica- 
tion of food, or talking may be almost impossible. The pain 
is often worse at night, but is more or less constant. If the 
furuncle is on the posterior wall, the auricle may be more 
prominent than usual, and pressure on any portion of the 
auricle causes intense pain. The tissues back of the ear are 
also often edematous when the furuncle is in this location. 
When the abscess is in the tissues of the anterior wall, the 
tissues in front of the ear often seem swollen. 

The cervical and preauricular lymphatics are often swol- 
len, and occasionally the parotid. Systemic symptoms are 
not always present. There may be a feeling of malaise, 
slight headache, and loss of appetite, but it is caused more by 
the pain and loss of sleep than an actual systemic infection. 
After forty-eight or ninety-six hours the distressing symp- 
toms usually subside quite suddenly, the furuncle having 
opened spontaneously and the contents escaping from the 
meatus as a purulent discharge, may lead to a diagnosis of 
middle ear suppuration, unless a careful inspection is made. 
Recurrence of the condition is the rule. If the tympanum 
or mastoid cells are implicated, the pain will be more in- 
tense, and systemic disturbances are more or less marked. 

Diagnosis. — Not always easy. In the early stages the 
pain is not localized, and an inspection of the canal may not 
reveal any disturbance. Palpation with a probe may reveal 
a sensitive area, and the examination should be made with- 
out using a speculum if possible, as the sensitive spot may 

• 34 



530 Nose, Throat and Ear. 

otherwise be covered by the speculum. When the furuncle 
is in the deeper portion of the canal, the speculum will 
usually be required. A slight redness of the affected spot 
may sometimes be detected. After swelling occurs, it is 
usually easy to determine the character of the condition, 
unless the tumefaction is sufficient to occlude the canal, 
when a positive diagnosis can not always be made. Pres- 
sure in front of the tragus will increase the pain, and aid 
in differentiating furunculosis from tympanic or mastoid in- 
flammation. Movement of the auricle in different direc- 
tions will also increase the pain when the inflammatory ac- 
tion is in the canal. 

Edema over the mastoid may occur, and lead to a diag- 
nosis of mastoid disease, but if firm pressure is made over 
the mastoid and care exercised not to impart motion to the 
canal, which can be done by making the pressure rather 
backward and inward, when the inflammatory process is 
confined to the canal, there is no increased tenderness. Sup- 
puration of the parotid gland may lead to an error in diag- 
nosis. The gland is often affected secondarily when the 
furuncle is located on the anteroinferior wall of the canal. 

Prognosis. — In uncomplicated cases the condition 
usually lasts from four to eight days, the severity of the 
attack being about" the third day. The tendency for re- 
curring attacks must be remembered. If uncomplicated 
there is not often any impairment of hearing. 

Treatment. — When the condition is recognized earl}-, a 
saturated alcoholic solution of boric acid has been claimed 
to be efficacious in aborting the boils. The method often 
employed of blood-letting is a relic of barbarism. For re- 
lief of the pain after swelling commences; the use of dry 
heat will sometimes be beneficial, Japanese pocket-stoves be- 
ing especially useful. The introduction of ple'dgets of cot- 
ton saturated with tincture of opium will probably relieve 
more cases than any other drug. A ten or twenty per cent 



Acute Circumscribed External Otitis. 531 

solution of menthol in albolene will sometimes give relief. 
The oil used should always be one that will not oxidize, as a 
rancid fat in the canal may cause a chronic eczematous af- 
fection that is difficult to cure. Poultices in the ear are 
also to be avoided, as they are likely to increase the liability 
of successive crops of boils. The use of white vaseline 
alone, or an ointment of boric acid in white vaseline will 
soften the integument and hasten rupture of the boil. It is 
the best practice in these cases to freely open the, boil as 
soon as it is plainly discernible, and not to wait until pus 
has formed. This can be done with but little pain to the 
patient if the furuncle is in the external portion of the 
meatus, by packing the canal below the tumefaction with 
cotton, then freeze the part with ethyl chloride. If the fu- 
runcle is in the deeper portion of the canal, cocaine in ab- 
solute alcohol and aniline oil aa, to make a twenty per cent 
solution, and used a few minutes before making the in- 
cision, will diminish the sensibility of the parts. The in- 
cision must be extensive enough to relieve the tension, a 
slight puncture simply increases the pain. The relief from 
tension and the hemorrhage following an incision will af- 
ford considerable relief. After an incision has been made, 
the canal may be douched with a solution of boric acid, or 
simply tepid water, but the stream of fluid should be con- 
tinuous, for ten or twenty minutes. A fountain syringe, 
or rubber tubing acting as a siphon, may be employed. 
Care should be taken that the receptacle for the fluid is only 
high enough so the water will flow into the canal without 
producing undue pressure «on the membrana tympani. Even 
after a free incision, there will be a discharge of blood- 
stained purulent material for several days, although the 
parts will return to their normal contour usually within 
twenty-four hours. Exuberant granulations may occur, but 
are readily removed by a sharp curette, or the application of 



532 Nose, Throat and Bar. 

saturated Lloyd's salicylic acid in thuja, nitrate of silver or 
chromic acid. The former solution is preferable. 

Internal treatment is valuable to prevent a recurrence. 
The bowels should be kept in an active condition, and cal- 
cium sulphide given to the point of saturation. Lime water 
is usually better for babies, as it can be given in milk or 
added to the drinking water. In anemic persons arsenic 
iodide should be employed. 

Chronic Circumscribed External Otitis. 

This is usually the result of an affection of the cartilag- 
inous or bony structures. If of the cartilage; it may be 
due to a severe type of acute furunculosis, and if of the 
bone, it usually is the result of some mastoid affection. 
These tumefactions are essentially chronic in character, and 
the only measure of relief is a free incision and removal or 
destruction of the sac by the use of the curette. 

Diffuse External Otitis. 

Either an acute or chronic type may occur, and it may 
affect the entire canal, or only a major portion. The line 
between the normal and affected parts is not clearly denned. 

Acute Diffuse External Otitis. 

Etiology. — Injury of the canal by mechanical means is 
a frequent cause. The use of aurilaves, hairpins, or similar 
implements for "cleaning the ear," are often the exciting 
factor. The use of escharotics may also be a cause. Some- 
times a furuncle may cause the condition. It may de- 
velop from exposure to cold, or may be a complication of 
influenza, the exanthemata, or typhoidal types of disease. 
The most frequent cause is a purulent otitis media, in which 
the tissues of the canal become infected through the surface 
being bathed with secretion. It frequently is an exacerba- 



Acute Diffuse External Otitis. 533 

tion of a former chronic condition. It may also be caused 
by instillation of various "ear-drops." 

Pathology. — The cellular tissue is the site of a diffuse 
inflammatory action. Severe congestion of the parts is soon 
followed by a profuse exosmosis causing an edema. In- 
frequently the formation of pus may follow, if the process is 
not controlled. 

Symptoms. — The initial symptom is a sensation of full- 
ness or discomfort, which rapidly becomes an intense pain. 
The systemic phenomena are, increased temperature of two 
or three degrees ; rapid pulse ; marked prostration ; head- 
ache ; loss of appetite, etc. The canal is closed by the 
edematous state, and the hearing impaired. Subjective 
noises are usually present. Pressure on the auricle in- 
creases the pain. The post-auricular and sub-auricular 
lymphatics are often affected, and occasionally the pre- 
auricular, and movement of the jaws intensifies the pain. 
Occasionally it is very difficult to open the mouth. 

Diagnosis. — Differentiated from furunculosis by the 
more marked systemic disturbances and more rapid devel- 
opment. The external third of the canal is often normal in 
size, and the introduction of a speculum does not cause 
much pain. The deeper portions of the canal are usually 
diminished in size, the swelling being most frequently from 
the supero-posterior wall, and the membrana tympani is 
more or less hidden from inspection. In severe cases com- 
plete occlusion of the canal may occur. A dead white color, 
the result of necrosis of the superficial epithelium, will be 
seen, and some moisture will cover the swelling. On re- 
moval of this covering, a reddened, moist looking surface is 
present. Probe palpation ; pressure in front of the tragus, 
or an upward and forward motion imparted to the canal is 
very painful. Edema back of the auricle may be present, 
and also some enlargement of the lymphatics along the an- 
terior border of the sternomastoid muscle. When this con- 



534 Nose, Throat and Ear. 

dition occurs, it is often difficult to differentiate between the 
external otitis and perforation at the tip of the mastoid, ex- 
cepting by the use of the speculum. Sometimes a diffuse 
inflammation may result from an acute purulent otitis media, 
and it is necessary to obtain a view of the membrana tym- 
pani to determine positively the condition. Patience in 
making the examination will usually give the physician a 
fairly satisfactory view of the druni membrane. 

Prognosis. — This depends considerably upon the excit- 
ing cause, but usually is of comparatively short duration, 
unless it is an exacerbation of a chronic lesion. 

Treatment. — Continuous irrigation with hot water, or if 
seen early, the introduction of pledgets of cotton saturated 
with aconite, veratrum aa 3j, aqua q. s. oiJ~J v > W1 h afford 
relief. In some cases the Leiter coil or ice bag will be most 
grateful. If relief does not follow within twenty- four hours, 
a free incision along the postero-superior or posterior wall 
is advisable, the incision being from one-half to three- 
fourths of an inch in length, and carried down to the bone. 
This should only be attempted under good illumination. 
After the operation, the canal should be freely irrigated 
every three or four hours until the discharge subsides, after 
which irrigation is injurious. When syringing is no longer 
necessary, the use of boric acid is most beneficial. 

Internal. — Thorough evacuation of the bowels by a saline 
cathartic, and the administration of apis, apocynum, or 
gelsemium are usually indicated. Aconite may be required 
if febrile symptoms are very marked. The food should be 
such as is easily assimilated. Opiates are seldom required. 

Chronic Diffuse External Otitis. 

This term is applied to any diffuse chronic inflammatory 
condition, whether of the superficial epithelial layer only, 
or when the entire canal, including bony and cartilaginous 
tissue is involved. 



Chronic Diffuse External Otitis. 535 

Etiology. — Traumatism of the canal is a common cause 
of this condition. The pernicious habit of "digging" into 
the external auditory canal with wash rags, towels, auri- 
laves, hair pins, etc., is a very prolific cause of a slight, per- 
sistent inflammation. The advice of Prof. Pomeroy "not 
to go into the canal of the ear with anything smaller than 
your elbow" was good. The tip of the little finger will go 
as deeply into the canal as is necessary for cleansing the ear. 
Injuries of the walls of the canal from any cause may pro- 
duce the condition. The use of ear drops, especially such 
as contain an oily base which oxidizes easily ; the introduc- 
tion of foreign bodies into the external auditory canal, and 
especially the existence of a chronic purulent discharge from 
the middle ear, are also causes of this condition. The 
growth of vegetable parasites in the canal is occasionally a 
factor. Eczema of the canal is often a cause, and is specially 
intractable, as it is a symptom of some systemic disturbance. 

Pathology. — This varies according to the exciting cause. 
In the mild forms, there is increased glandular activity. 
When the interglandular tissue is affected, there follows 
some infiltration of the deeper layers of the integument. 
The amount of serum exuded depends upon the severity of 
the process. When profuse, the surface after cleansing, re- 
veals a glistening, smooth red surface. If the exudate is 
scanty, it dries and with the desquamated epithelial scales, 
forms yellowish crusts, which more or less occlude the 
canal. If not checked, an actual hypertrophy of the base- 
ment membrane results, narrowing the canal. If the in- 
flammatory process is in the bony portion of the canal, the 
bony tissue may be implicated, and even the tympanum. In 
this location it is often difficult to differentiate from mas- 
toid disease. 

When the inflammatory action is the result of foreign 
bodies, traumatisms, or the development of vegetable para- 
sites, the character of the changes are similar to those al- 



536 Nose, Throat and Ear. 

ready described, but vary in intensity. Occasionally there 
is a rapid proliferation of the epithelial layer, the cells rap- 
idly forming a compact mass which fills the deeper por- 
tion of the canal. 

In some cases the deeper portions may be the starting 
point, and later affect the canal walls. This occurs most 
frequently when the process is located in the bony walls. 

If the condition is due to vegetable fungi, a microscopic 
examination alone will determine the exciting cause. 

Symptoms. — These will depend upon t4ie exciting fac- 
tor as well as the intensity of the inflammatory process. In 
mild cases there is a sensation of irritation or itching. If 
due to increased glandular activity, eczema, otomycosis, or 
fungi, which occlude the canal, impaired hearing or a tin- 
nitus may be the most prominent subjective symptoms. In 
some there are reflex manifestations, as headache, pain 
along the branches of the fifth nerve, occasionally epilepti- 
form attacks, and not infrequently sneezing or a paroxysmal 
cough. Autophony may be an annoying feature when the 
canal is nearly closed. A scanty secretion, drying in crusts 
around the opening of the canal, or a comparatively profuse 
watery discharge may be present. Not infrequently the 
lymphatics around the auricle are enlarged. 

Diagnosis. — When the inflammation is confined to the 
canal, pressure directed backward and inward behind the 
auricle, will not reveal any tenderness, but if the pressure is 
directed forward, moving the fibrocartilaginous portion of 
the canal, tenderness or pain will be complained of. Palpa- 
tion above, below, or in front of the canal, will cause more 
pain than when made over the mastoid. Inspection of the 
canal will show varying conditions depending upon the 
severity of the attack as well as the cause. In the milder 
types, which include seborrhea, eczema, or aspergillus, the 
walls are more or less covered by some incrustation. In 
seborrhea it is usually limited to the cartilaginous portion, 



Chronic Diffuse External Otitis. 537 

and appears as small, thin, yellowish crusts or scales which 
are easily removed, and have an oily feel. The removal of 
the crusts shows a reddened surface which is not moist. In 
eczema, the crusts are larger, more firmly adherent, and the 
morbid process extends from the external opening to the 
membrana tympani. The removal of the yellowish brown 
crusts reveals a reddened, moist surface, upon which a thin 
serum soon forms when the surface has been dried with 
cotton. The walls of the canal appear thickened, and probe 
palpation shows this condition is present. 

When due to fungi, in the mild type the walls of the 
canal are more or less covered by a whitish or yellowish- 
white coating, which appears to be closely adherent to the 
canal walls. The cotton used in wiping the canal will re- 
move either scales or even an almost perfect cast of the 
canal, leaving a denuded appearance of the walls. A 
microscopic examination will be necessary to determine the 
character of the fungi. Macroscopic appearances will often 
aid in determining the character of the variety of fungus. 
When white, it is usually aspergillus glaucus. Occasionally, 
the canal walls and surface of the membrane may be dotted 
with small dark or black spots, which are the sporangia of 
aspergillus niger. 

In desquamative inflammation, there will be found a 
compact, whitish mass, in the deeper portion of the canal. 
This is easily penetrated with a probe or curette, but is 
rather difficult to remove. The canal walls are usually 
moist, and have a macerated appearance. The superficial 
epithelium is easily wiped off with cotton. 

If the process is a manifestation of mastoid inflammatory 
action, the. superior and posterior walls close to the mem- 
brana tympani are usually most affected. The distinct out- 
line between the drum head and the canal wall is more or 
less obliterated as a result of the bulging of the canal walls. 

Prognosis. — This will depend upon the exciting cause as 



53& Nose, Throat and Kar. 

well as the length of time the morbid process has been pres- 
ent. More or less impairment of hearing may result, and in 
some cases recurrence of the condition may be expected, no 
matter what the treatment. 

Treatment. — Locally. — The salicylic acid ointment will 
often prove beneficial in eczematous or glandular types. In 
some cases the eucalyptus ointment will be effective. The 
compound stearate of zinc and tar is useful for relieving 
the itching. If the condition is the result of fungi, the use 
of salicylic acid ointment, stearate of zinc with salicylic 
acid medium, oxide of zinc, or boracic acid twenty parts, 
salicylic acid one part, will afford relief. Fluids usually 
aggravate the condition and should seldom be used. 

■ Internally. — Liquor potassii arsenitis, arsenous acid, ar- 
senic iodide, Phytolacca, hydrastis, or jaborandi are usually 
indicated. 

Croupous and Diphtheritic External Otitis. 

These are infrequent forms of diffuse external otitis, 
and the croupous is seldom seen. In either type the exu- 
date partakes of the characteristics of the same condition 
in the throat or nose, modified in a measure by its location. 
The treatment will be similar to the same affections on the 
mucous surfaces. 

Hemorrhagic External Otitis. 

This may be either primary or secondary. The anterior 
and inferior walls of the canal are most frequently affected. 
Vesicles filled with a bloody fluid form, and if undisturbed, 
disappear in a few days, leaving at their site excoriated 
spots. There is severe pain, sometimes neuralgic in charac- 
ter ; elevation of temperature ; considerable general prostra- 
tion, and infrequently delirium. The condition is some- 
times present in epidemic influenza. When idiopathic, 



Impacted Cerumen. 539 

Dench considers it a tropho-neurosis, or a complication of 
a simple diffuse otitis. 

Treatment. — Usually systemic. 

Impacted Cerumen. 

Etiology. — Impacted cerumen may result from an over- 
activity of the ceruminous glands, or from some anatomical 
or mechanical interference with the free exit of the secre- 
tion from the canal. The occupation has an influence, as 
those who work in a dusty atmosphere are often affected on 
account of the floating material mingling with the secretion, 
causing it to become less fluid. After a variable length of 
time, when there is an obstructive condition, there will be 
formed a ceruminous plug, varying in size and consistency. 

Pathology. — In simple cases of impacted cerumen, the 
mass when removed, will be found to be composed of the 
natural oily material, often vegetable spores, dust, and not 
infrequently in the center a foreign body which forms a 
nucleus for the cerumen. The plug is often covered with 
desquamated epithelium. If the mass is of considerable size, 
the morbid process is more complete, and a chronic desqua- 
mative inflammation of the deeper portion of the canal is 
present as a result of the presence of the impaction which 
acts as a foreign body. This impaction probably tends to 
increase the activity of the glands. When desquamative in- 
flammation complicates the presence of a ceruminous mass,' 
either the deeper portion of the canal may be much en- 
larged, or the bony walls may be partially destroyed. The 
posterior wall is most frequently affected, and the pneumatic 
mastoid spaces may be destroyed. Occasionally a chronic 
osteitis results from the pressure, and the mastoid cells are 
not only destroyed, but sclerosis of the entire process with 
ivory-like material follows. Perforation of the membrana 
tympani may occur from the pressure, and serious morbid 
changes result in the tympanum. 



54^ Nose, Throat and Ear. 

Symptoms. — These vary according to the size of the im- 
paction, its location, and the amount of inflammatory ac- 
tion induced by its presence. There may be impaired hear- 
ing, tinnitus, autophony, a sensation of fullness, or a dull 
aching. In many cases there will be no subjective symp- 
toms until the patient has taken a plunge bath, or in swim- 
ming or washing, water has entered the canal, which causes 
swelling of the hardened mass, closing the canal and pro- 
ducing some of the symptoms spoken of. Not infrequently 
a person will complain of getting water in the ear and not 
being able to get it out. In some cases there is a gradual 
diminution of hearing, and finally tinnitus or autophony. 
The pressure exerted may cause a severe neuralgic pain 
which may extend to the temporal and supraorbital regions, 
or affect the entire trigeminal branches. A sensation of 
numbness is not infrequently complained of, affecting not 
only the ear but also the entire side of the face. 

Reflex phenomena are frequently present. Cough is 
most often complained of. The cough is spasmodic and 
often very severe. One case of asthma was relieved of 
the attacks by the removal of a ceruminous plug from the 
right ear. Hebetude is sometimes a prominent feature. The 
fellow ear is occasionally affected by the presence of an im- 
paction in the canal of one ear. Epileptiform attacks or 
spells of vertigo may result from an impaction. 

Diagnosis. — The only positive method of making a diag- 
nosis is by inspection of the canal. 

Prognosis. — Favorable so far as the removal of the mass 
is concerned, but guarded as to a recurrence of the condi- 
tion, or as regards restoration of hearing. If of long stand- 
ing, the probabilities are that impaired audition will re- 
main after the ceruminous material has been removed. Not 
infrequently after the removal of a mass of cerumen there 
follows an acute diffuse inflammation of the canal, or fu- 
runcles may appear. If no special changes have occurred in 



Impacted Cerumen. 541 

the tissues of the canal, there is usually a return of com- 
paratively normal function. 

Treatment. — Syringing is the best method for removing 
the mass, in the majority of cases being all that is required. 
In exceptional cases a probe or curette may be needed, but 
considerable skill is necessary in their use, as much dam- 
age' may result from clumsy handling of the instruments. 
In the use of the syringe, it is important that the stream 
of warm water should be properly directed. The canal 
should be straightened by pulling the auricle upward and 
backward, the water being directed along the superior wall 
of the canal, unless there is more space along one of the lat- 
eral walls. The removal of the plug results from the force 
of the fluid back of it, causing it to be swept toward the ex- 
ternal opening. If the entire canal appears blocked by the 
mass, a blunt curette or blunt spud may be used to loosen 
or remove some of the material. The force of the stream 
must be graduated to the sensations of the patient. If dizzi- 
ness occurs, the force should be diminished. It is always 
preferable to first throw some of the fluid around the open- 
ing of the canal. The water should be comfortably warm 
to the patient. Infrequently a case is found in which the 
syringe will not remove the mass, and the blunt curette must 
be employed. In such a case the curette should be used 
along the posterior wall, making traction outward. After 
part of the material has been removed, the syringe will 
usually bring the balance away without much difficulty. In 
very exceptional cases, forceps will be required, but skill in 
their use is necessary. After the removal of the plug, the 
canal should be wiped with cotton, and in cold weather it 
is best to place a pledget of cotton in the canal and allow 
it to remain unfril bedtime. An inspection of the ear should 
be made within forty-eight hours, as a definite idea of the 
condition can not be obtained after syringing on account 
of the maceration of the tissues. 



CHAPTER XXVII. 
FOREIGN BODIES IN THE CANAL. 

Under this heading may be included anything small 
enough to enter the canal. In children, or the feeble- 
minded, the introduction of various inanimate foreign 
bodies is not uncommon. Insects may enter the canal, and 
in suppurating conditions, maggots may be found. Among 
inanimate bodies introduced into the external auditory canal, 
the division must be made of inorganic and organic, as in 
the latter case swelling of the object may occur, which will 
cause severe pain. 

Symptoms. — The symptoms, when inorganic, do not vary 
particularly from those given under impacted cerumen. The 
location will have an influence, for if the body is small and 
hard and rests against the drum membrane, more or less 
pain is liable to occur. If organic, and dry when intro- 
duced, the absorption of moisture often causes increasing 
pain, and may swell sufficiently to render it difficult to re- 
move. If the foreign body is an insect or larvae, the pain 
is usually so intense as to cause the patient to seek imme- 
diate relief. 

Diagnosis. — If seen early, and unavailing attempts at 
removal have not been made, there usually is little diffi- 
culty in recognizing a foreign body, but when unskillful 
efforts at removal have been made, the swollen condition 
of the canal and often coagulated or dried blood render a 
diagnosis difficult, excepting from the history. 

Prognosis. — Usually favorable, but where unsuccessful 
attempts at removal have been made, the tissues lacerated, 
and, as occasionally occurs, the foreign body has been pushed 

$42 



Foreign Bodies in the Canal. 



543 



through the membrana tympani into the tympanum, the 
prognosis may be unfavorable. The presence of the foreign 



<^ 



MAX WOCHER Sl SON, OIN, 



-A 



Fig. ioi. Quier's Foreign Body Instrument. 




FlG. 102. Alligator Jaw Forceps. 



body is often less injurious than the bungling efforts made 
for its removal. 

Treatment. — In practically every case the simplest and 
safest instrument is the syringe. It is very seldom an ob- 
ject can not be removed from the external auditory canal 
by this means. If the stream of water is thrown along the 




EiG. 103. Wilde's Ear Forceps. 



544 Nose, Throat and Bar. 

superior wall of the canal, the return flow will usually carry 
the offending substance with it. In some cases a curette, 
Ouier's foreign body instrument, or a blunt hook may be ad- 
vantageously used. Forceps are seldom required, and 
usually simply force the body deeper into the canal. If the 
object is soft or friable, it may be necessary to break it into 
small fragments before it can be removed. In some cases 
general anesthesia is necessary. 

Infrequently cases are encountered where it is impossi- 
ble to remove the foreign body through the external meatus 
on account of the swollen condition, and resort to radical 
measures are necessary, but the novice should never attempt 
such a procedure. 



CHAPTER XXVIII. 

EXOSTOSES OF THE EXTERNAL 
AUDITORY CANAL. 

Etiology.- — Long continued irritation of the canal, es- 
pecially in chronic purulent otitis media, appears to be a 
.common factor. The condition is not as often seen among 
Americans as Europeans. There appears to be an heredi- 
tary predisposition in some cases to these growths. 

Pathology. — Exostoses usually occur either at the junc- 
tion of the bony and cartilaginous portion of the canal or 
deeper in the bony portion. One of two forms will be found, 
either having a broad base or as pedunculated masses. They 
may be cancellous or the so-called ivory exostoses. They 
are usually multiple. If but one, and it is of considerable 
size, the protrusion of the growth may cause the canal to 
have a slit-like appearance. 

Symptoms. — If small, there are often no subjective 
symptoms, but if of sufficient size to occlude the canal, im- 
paired hearing may result. In these latter cases, there is 
often a sensation of fullness or stuffiness in the ear, au- 
tophony and usually tinnitus. Collection of the normal se- 
cretion behind the growths causes a constantly increasing 
pressure upon the drum membrane as well as the walls of 
the canal, and a constant irritation will result, if it is not 
removed. An acute otitis media, or an acute external 
otitis may result from this accumulation, especially if water 
enters the canal causing swelling of the material. 

Diagnosis. — Usually an inspection of the canal will de- 
termine the condition. If the growths are covered by ceru- 
35 545 



546 Nose, Throat and Ear. 

men or epithelial scales, syringing the canal will remove the 
covering material, or the use of a probe will determine the 
character of the growth. 

Prognosis. — Guarded, so far as restoration of normal 
function is concerned, but usually favorable as regards life. 
The chance of an exostosis degenerating into a malignant 
growth should be remembered, especially if it is located near 
the orifice of the canal. Recurrence after removal is in- 
frequent. 

Treatment. — Operative. If the growth is pedunculated 
and situated well forward in the canal, a chisel will suffice. 
If the base is broad, it is usually necessary to use small 
drills in a dental engine, or a radical operation may be re- 
quired. It is not advisable for the general practitioner to 
attempt these operations. 



CHAPTER XXIX. 

INJURIES AND DISEASES OF THE 

MEMBRANA TYMPANI AND 

TYMPANUM. 

Etiology. — Injuries of the drum head may result either 
from direct or indirect means. Direct may be from the use 
of instruments, or through the introduction of foreign 
bodies into the canal. Indirect means may be through sud- 
den condensation of the air in the canal by a "box" on the 
ear, the concussion following the discharge of heavy ord- 
nance or a heavy explosion. Severe traction of the auricle, 
especially in children, may cause rupture of the membrana 
tympani. In intense inflammatory action in the canal, there 
may occur necrosis of the membrane, a perforation resulting. 

Pathology. — If the injury is from the introduction of 
instruments, or implements for cleansing the canal or re- 
lieving irritation, it is usually located in the upper and 
posterior quadrant. If the result of concussion, the pos- 
terior superior quadrant is usually the location. If from 
traction upon the auricle, the membrana flaccida is oftenest 
ruptured. Ruptures due to traumatism usually are single, 
and their form varies considerably. 

Symptoms. — Severe pain is the first symptom of rupture 
of the membrane from either instrumental manipulation or 
concussion. The hearing is impaired and tinnitus is de- 
cidedly marked. Vertigo usually follows a blow upon the 
ear, but is more the result of sudden increase of tension in 
the inner ear than the rupture of the membrane. In a short 
time the pain decreases and there is a thin watery discharge 

547 



548 Nose, Throat and Ear. 

in the canal. Blowing the nose will usually produce a 
whistling sound in the ear. Not infrequently a tedious sup- 
purative process follows the injury, although if there is no 
injury of the tympanum, healing soon occurs. 

Diagnosis. — An otoscopic examination will verify the 
history of an injury. In the membrana flaccida, ruptures 
are not so readily recognized as when in the membrana 
vibrans. 

Prognosis. — Favorable in the majority of cases, unless 
injury of the middle ear structures or of the labyrinth has 
resulted from the injury. 

Treatment. — If the perforation is the result of surgical 
manipulation, the drying of the canal and membrane with 
cotton, a slight dusting of the surface with boric acid and 
introducing a pledget of cotton in the canal, will be all that 
is required. If there should be sufficient serous discharge 
to saturate the cotton, the patient should be instructed to re- 
place the moistened cotton with a dry pledget as often as is 
necessary. Usually healing occurs in twenty-four hours. 
In other cases the same general line of treatment should be 
followed, and only in extreme conditions should fluids be 
used in the ear, as the maceration of the tissues is liable to 
produce a suppurative condition. 

Myringitis. 

It is a question whether an independent inflammation of 
the membrana tympani can occur. Some aurists claim such 
a condition may be found and recognize an acute and 
chronic form. In the acute type, part or all of the mem- 
brane may be congested. In the later stages of the acute, 
or occasionally in the chronic form, there may be an effusion 
of serum in the dermal layer and also slight effusions of 
blood. Vesicles filled with serum frequently develop. 

Symptoms. — Pain, varying in intensity, is present. Tin- 
nitus and a pulsating noise is often complained of. Impair- 



Tubal Congestion. 549 

ment of hearing is less than in acute otitis media. In four 
or five days the condition usually is cured. 

Treatment — The use of boric acid insufflations is suffi- 
cient. 

Inflammation of the Middle Ear. 

The lining membrane of the entire middle ear is mucous 
membrane, and this membrane is subject to the same path- 
ological changes as mucous membranes in other regions of 
the body. These have already been considered and will not 
be repeated, only to emphasize the fact that more or less 
occlusion of the Eustachian tube may result from tubal in- 
flammation ; ankylosis of the ossicles follow some exudative 
forms of inflammation in the tympanum ; or by extension 
from the tympanum there may be a mastoiditis with its at- 
tending menace to life. 

Tubal Congestion. 

Synonyms. — Tubal Catarrh; Acute Salpingitis; Eusta- 
chian Catarrh. 

Etiology. — Usually results from an acute rhinitis or an 
acute nasopharyngitis. In young adults it sometimes is a 
complication of the exanthemata. The use of the nasal 
douche, post-nasal syringe, or even the atomizer, may cause 
the condition by some of the fluid entering the tube. Ade- 
noids are frequent factors in this affection. 

Pathology. — This may be divided into ( 1 ) The changes 
in the Eustachian rnucous membrane. (2) The changes in 
the tympanum through lack of patency of the tubes. 

The tubal change is usually that of a venous hyperemia, 
but an inflammatory condition may be present. The mucous 
membrane is swollen and relaxed, the opposite walls being, 
in contact with each other and adhesion resulting through 
the character of the secretion. Exudation of the blood ele- 
ments results from the venous hyperemia, and when the 



550 Nose, Throat and Ear. 

process is fully developed, the exudate is thick, tenacious, 
white and glairy, and often completely closes the tube. The 
cartilaginous portion of the tube is usually the most affected. 

In closure of the tube, the air confined within the tym- 
panum is rapidly absorbed, the membrana tympani, as a 
result of the diminished atmospheric pressure in the cavity, 
being pressed inward by the external pressure. In cases of 
long continued closure of the tubes, the membrane at the tip 
of the manubrium, may actually be in contact with the inner 
wall. 

Symptoms. — When the condition is the result of a 
rhinitis or rhinopharyngitis, the symptoms usually appear 
suddenly. There is a sensation of stiffness or heaviness in 
the ear, and the patient places the tip of the finger against 
the orifice of the auditory canal in order to improve the 
hearing or relieve the sensation. Sometimes there is pain 
in the tonsillar region or the vault of the pharynx. The 
hearing is impaired, and subjective noises may be extremely 
annoying. The pitch of these sounds is usually high, and 
in persons who are plethoric, there may be an intensity of 
the sound with each systole. In some cases as a result of 
the sudden increase of pressure in the labyrinth, vertigo 
may be present. A feeling of mental dullness may be no- 
ticed, and apprehensiveness is not uncommon. 

In some persons any exposure to cold will cause tubal 
congestion, and while not affecting the hearing, there will 
be subjective symptoms which are very annoying. These 
may be the sensation of a foreign body in the pharynx, or 
an acute pain at the base of the tongue. 

Diagnosis. — Inspection will show a retracted membrana 
tympani, the manubrium more or less obscure while the 
short process is more prominent. The appearance of the 
membrane is normal, but the light reflex may be absent, 
broken, displaced or multiple. Inflation of the middle ear 
is difficult. Inspection of the nasal cavities and naso- 



Tubal Congestion. 551 

pharynx will usually reveal congestion or inflammation in 
one of these regions, besides more or less turgescence of 
the tissue surrounding the tubal orifice. 

Functional tests will show diminished audition. This 
is probably due to some disturbance in the equilibrium of 
the labyrinthine fluid. The sudden obstruction of the 
Eustachian tube may cause a traumatic condition of the 
labyrinth similar to that produced by the concussion of an 
explosive or a blow upon the ear. An examination of the 
ear in the early stage may show the hearing is fairly good 
for low tones, the upper tone limit lessened, and bone con- 
duction diminished. This condition shows a secondary im- 
plication of the labyrinth, and is amenable to treatment. 
The clinical history, an inspection of the membrane, nose 
and post-nasal space, will establish the diagnosis. 

P?'o gnosis.— Good, but the liability of recurring attacks 
should be remembered. The normal hearing usually is not 
recovered for several weeks. 

Treatment. — I consider the method usually employed of 
inflating the ear as pernicious. It is true that temporary 
relief follows this procedure, but experience has shown that 
recovery is slow, and recurrence more frequent. There is 
a congestion or inflammation present, and the forcible dila- 
tation of the tube by the air current will necessarily in- 
crease the morbid process. There is also danger of for- 
cing the tubal secretion into the tympanum. 

Internal medication promises the best and quickest re- 
sults. The remedies most frequently required are aconite, 
gelsemium, phytolacca, bryonia, Pulsatilla, jaborandi, liquor 
potassii arsenitis, belladonna, hamamelis, potassium bichro- 
mate, potassium iodide. 

Hygienic measures should be insisted upon the same 
as in catarrhal conditions of the nose or throat. Abnor- 
malities of the nasal or nasopharyngeal tissues should be 
corrected, provided they are of such a character as to be 



552 Nose, Throat and Ear. 

either a secondary exciting factor or cause a continuation 
of the process when once established. 

Acute Tubo-Tympanitis. 

Synonyms. — Tubo-tympanic catarrh ; Tubo-tympanic 
congestion. 

Etiology. — This condition is produced by the same 
causes as tubal catarrh, but the tympanic mucous mem- 
brane is implicated as a sequence of the tubal occlusion. 

Pathology. — Hyperemia of the inner wall of the tym- 
panum and also slight hyperemia of the membrana tympani 




Fig. 104. Effusion into the Tympanum. (After Politzer.) 

as a result of engorgement of the vessels, is present. The 
congestion may result in hypersecretion and accumulation 
of mucus in the tympanum, or a simple serous exudate. 
This occurs most frequently in persons of a gouty diathesis, 
or in chronic cardiac, hepatic or renal affections. In the 
membrana tympani the venous congestion will show in the 
upper and posterior portions near the periphery and also 
along the handle of the malleus. Occasionally there will be 
sufficient exudation into the tympanum to cause bulging of, 
and even threaten rupture of the membrane. 

Symptoms. — There is often pain in the ear, and tinnitus 
may be very marked, especially when the patient is in the 
recumbent position. Vertigo is a frequent symptom, es- 



Acute) Catarrhal Otitis Media. 553 

pecially when the head is .suddenly moved backward or to 
either side. There is often a bubbling or snapping sound 
in blowing the nose, and also at times on swallowing. 
Autophony is often an annoying symptom, and some notes 
produce a sensation of pain. Auto-inflation often improves 
the hearing, but sudden impairment may follow the act of 
swallowing. 

Diagnosis. — Inspection of the membrane will show some 
retraction and a pinkish tinge or a dull white color. At 
the periphery and along the handle of the malleus a marked 
change in color will be found. The change in the position 
of the membrane is not so marked as in simple tubal oc- 
clusion. If an exudate is present in the tympanum, the 
lower portion of the membrana tympani will have a slight 
yellowish tinge, while the portion above the fluid will have 
a more natural appearance. Aerial conduction is lessened 
for all sounds. Usually bone conduction is increased, and 
if the fork is held on the forehead or vertex, the vibrations 
are heard more distinctly in the ear most affected. 

Prognosis. — In children complete restoration of hearing 
usually results, but in adults there is often some diminution 
of hearing. 

Treatment. — This does not differ materially from that 
of simple tubal catarrh. 

Acute Catarrhal Otitis Media. 

Synonyms. — Otitis Media Catarrhalis Acuta; Earache. 

This is a true inflammatory condition of the tympanic 
mucous membrane. 

Etiology. — This condition may be a complication in 
acute infectious diseases, especially the exanthemata, or it 
may result from a rhinitis or pharyngitis. The use of the 
nasal douche, or violent efforts to clear the nasal cavities, 
may be a cause. In teething children earache is not un- 
common. Abnormal conditions in the nasopharynx pre- 



554 Nosk, Throat and Bar. 

disposes to this condition. Exposure to cold or wet often 
causes an acute catarrh of the middle ear. 

Pathology. — Similar to that of mucous membrane gen- 
erally. 

Symptoms. — As the symptoms vary according to the 
age of the patient, a division is made for convenience. 

In young children the attack may be so severe that a 
diagnosis of meningeal or cerebral disease is often made. 
The attack usually comes on at night, and the first indica- 
tions of illness will be restlessness, the arms being raised 
above the head, and often to the affected side. The child 
soon wakens, usually with a sharp cry of pain. The tem- 
perature as a rule varies from 102 to 104 . The child 
usually, on being lifted from its bed, presses the affected 
ear against the breast of the party carrying it, and its 
screams are symptomatic of agony. It is not the fretful 
cry of cerebral irritation, nor the peculiar moaning cry of 
meningitis. Excepting in the infrequent condition of both 
ears being affected at the same time, there is not the disposi- 
tion to throw the head backward. Spasms or vomiting may 
occur prior to or during the height of the attack; if this 
occurs, the differential diagnosis between an acute catarrh 
of the middle ear and meningitis is often difficult, unless 
an examination of the ear is made. After a variable period 
(the membrane ruptures, and a sero-mucous discharge will 
be found in the canal. When rupture occurs, there is 
usually a diminution of the pain, the temperature is re- 
duced, and the child soon goes to sleep; but as the inflam- 
matory action is liable to continue for several days, a nor- 
mal temperature is not to be expected at once. 

The first few days the discharge is profuse, turbid from 
the admixture of epithelial cells, and as there is usually 
considerable mucin present, the secretion is rather viscid. 
On account of this viscidity free escape of the discharge is 
impossible unless the opening in the drumhead is of consid- 



Acute Catarrhal Otitis Media. . 555 

erable size, and obstructive symptoms may result. After a 
few days the discharge becomes thin and watery, and often 
entirely ceases. If properly treated, the discharge does not 
become purulent, but in neglected cases a purulent dis- 
charge will often follow in a short time, and finally result 
in a chronic purulent otitis media. If the perforation in 
the membrana tympani becomes closed through any cause 
before the catarrhal process has subsided, there will be a 
return of the constitutional phenomena. 

In adults the early symptoms may be so slight as to be 
ignored. Later there is a sensation of fullness in the ear, 
soon followed by pain, which steadily increases in intensity, 
and makes it practically impossible to sleep. Usually the 
pain is localized, and intensified on lying down. Subjective 
noises of a high pitch are usually present. The acuity of 
hearing is generally impaired, and almost total deafness in 
the affected ear may temporarily occur. The pain grad- 
ually diminishes after profuse secretion occurs, but there 
is a sensation of fullness or heaviness in that side of the 
head. On swallowing there is usually a sharp pain, often 
extending from the pharynx to the ear, and air passing into 
the tympanum and through its fluid contents produces a 
bubbling sound. There is seldom any febrile symptoms, 
but considerable prostration may result from the severe 
pain. Rupture of the tympanic membrane may take place 
within forty-eight hours, but in many cases this does not 
occur, and the sero-mucus in the tympanum produces the 
characteristic symptoms of an intratympanic effusion. When 
rupture occurs, there is usually an abrupt diminution of 
pain, and the presence of a sero-mucous discharge in the 
canal. When rupture of the drum membrane does not oc- 
cur, the vault of the tympanum may be implicated, and at 
times the mastoid region is invaded by the morbid process. 
There is intense pain back of the auricle, which gradually 
involves almost the entire side of the head. In this condi- 



556 Nose, Throat and Ear. 

tion there is usually increased temperature, as well as more 
severe local symptoms. If rupture of the drum membrane 
occurs, there may be a spontaneous cessation of the condi- 
tion, or it may become a chronic purulent otitis media. 

Diagnosis. — This must be made both from the history, 
symptoms, and an inspection of the membrana tympani. In 
the early stages there is a marked hyperemia of the mem- 
brana tympani, especially along the handle of the malleus. 
The membrana flaccida is also hyperemic, and often the 
drum membrane is depressed. In the later stages the mem- 
brane is uniformly reddened, the landmarks obliterated, and 
a bulging may be seen. After the discharge has com-, 
menced, the canal of the ear will be found filled with sero- 
mucus. After this is removed the membrana tympani will 
show a white, dull coating, the result of necrosis of the 
superficial epithelium. On the removal of this coating 
with cotton, the membrane will appear red and swollen. 
The location of the rupture is usually easy, unless the canal 
is swollen. Rupture may occur in any part of the mem- 
brane, but is usually located in the inferior half. 

Prognosis. — Usually favorable, even without treatment, 
but a chronic purulent otitis media, or even a mastoiditis, 
may follow. If perforation does not occur, complete reso- 
lution may not take place, and infrequently inspissated ma- 
terial remains in the tympanum, which may be a source of 
annoyance to the patient. One. case that I had under treat- 
ment for this condition, the removal of this mass of in- 
spissated material by incising the membrane and removing 
the mass with forceps gave immediate and complete relief. 

Treatment. — The most imperative indication is for the 
relief of the pain, and in the majority of cases the use of 
chloroform vapor will be most satisfactory. The method 
usually employed is to pour about half a dram of chloroform 
into a DeVilbiss powder blower, and by the use of the bulb 
force the vapor into the external auditory canal. Care must 



Acute Purulent Otitis Media. 557 

be exercised, so none of the liquid is thrown into the canal, 
as it will increase the pain and blister the integument. The 
use of the chloroform vapor has relieved ninety per cent 
of the cases in my practice. If this does not afford relief, 
either blowing warm tobacco smoke into the ear, using a 
common clay pipe, in the bowl of which is placed a live 
coal, and placing some tobacco over the coal, then placing 
the end of the stem at the opening of the canal, blowing 
through the bowl, will cause the hot air and tobacco smoke 
to enter the canal. Hot water used with a fountain syringe, 
having the bag just high enough so the water will flow 
gently into the canal, and increasing the temperature of 
the water gradually, as the patient can bear it, is also a 
measure that will often afford relief, but should not be em- 
ployed excepting as a last resort. 

The use of leeches around the ear, or of oily instillations 
into the canal is reprehensible. . 

Internally the use of Pulsatilla and gelsemium will 
usually materially aid the local measures in relieving the 
pain. A saline cathartic can often be given to advantage. 
The use of opiates is infrequently necessary if the above 
measures have been employed. 

Operative procedures are sometimes required, paracen- 
tesis of the membrane, especially when there is bulging from 
an accumulation of secretion in the tympanum. In young 
children it is better to use general anesthesia, but in adults 
the use of a fifteen per cent solution of cocaine in equal parts 
of absolute alcohol and analine pure, will be sufficient. The 
incision should be made at the most prominent point, or in 
the posterior-inferior quadrant, and close to the periphery 
of the membrane. 

Acute Purulent Otitis Media. 

Synonyms. — Otitis Media Purulenta. Acute Purulent 
Discharge from the Middle Ear. 



558 Nose, Throat and Ear. 

The presence of pus is always significant of necrosis 
of the deeper tissues of the affected region, and in the 
tympanum the superior portion is most often implicated in 
this type of inflammation. A primary purulent otitis media 
is characteristic in this region. 

Etiology. — The acute infectious diseases are the most 
common causes of this condition. The entrance of fluids 
into the tympanum through the Eustachian tube is also a 
frequent factor. Extension of an external otitis, by pass- 
ing through the Rivinian segment may also be a cause. 
Rupture of the membrana tympani from any cause may 
be followed by a purulent discharge. 

Pathology. — This does not vary particularly from a 
purulent inflammation of mucous tissue elsewhere, except- 
ing as it is in a confined space, and the liability of extension 
of the morbid process to the brain or mastoid must be con- 
sidered. 

Symptoms. — The most prominent symptom is the sud- 
den and intense pain in the ear. There is also increased 
temperature, headache, systemic depression, and usually 
constipation. Impaired hearing, an annoying tinnitus and 
occasionally vertigo are usually complained of. In children 
the symptoms are intensified, convulsions often ushering in 
the attack. In adults there may be delirium in severe cases. 
The temperature is much higher than in an acute catarrhal 
inflammation, and the systemic disturbances are also more 
marked. Unless relieved, the pain is continuous, until 
thorough evacuation of the inflammatory products occurs, 
and if the rupture in the membrane is not of considerable 
size, and occasionally when it is, there is only partial abate- 
ment of the pain. The mastoid may become implicated at 
any time during the progress of the disease, when there 
will be an increase of all the symptoms. Sometimes the in- 
tracranial structures are affected, and the usual line of 
symptoms of cerebral lesions will be noted. These symp- 
toms depend upon the region and area involved. 



Acute Purulent Otitis Media. 559 

The labyrinth may be affected, and then sudden attacks 
of dizziness, nausea, and more or less deafness results. It 
is not often that the labyrinth is involved, but as it some- 
times occurs, the symptoms and seriousness of the condi- 
tion should be remembered. 

Diagnosis. — As there is danger of serious impairment 
of hearing, as well as of life itself, in this disease, an early 
recognition of the condition is important. A careful ex- 
amination of the membrane should be made, especially of 
the upper portion, as in the early stages this is frequently 
the only part showing any abnormal change. Congestion 
of a deep, dull-red color will be observed, and does not ex- 
tend below and often not as far as the posterior fold. As the 
process continues, there will be a decided engorgement of 
the tissues, the membrana flaccida being pushed outward 
and a little downward. Occasionally the swelling and 
edema may be sufficient to overhang the short process. 
Eventually the hyperemia involves the entire membrana 
tympani, and the outline of the manubrium usually can 
not be discerned. 

When it is a complication of scarlet fever or any sud- 
den acute infectious condition, the true character may be 
obscured by the dead white color of the membrane, caused 
by the necrosis of the superficial epithelium. This necrosed 
layer is readily removed with cotton, and the reddened 
membrane revealed. If the secretions have gravitated into 
the lower portion of the tympanum, the entire drum mem- 
brane may present a bulging into the canal. Occasionally 
the secretion may be retained by the mucous folds and form 
several tumefactions in the upper segment of the membrane. 
Spontaneous rupture usually occurs in the posterior por- 
tion of the membrane, above the center and near the pe- 
riphery, but may occur in the membrana flaccida. 

Functional examination of the ear gives practically the 
same results as in an acute catarrhal otitis media. If the 



560 Nose, Throat and Ear. 

labyrinth is invaded by the process there is lessened bone 
conduction and the upper notes of the scale are not heard. 

Prognosis. — Prior to the formation of pus, spontaneous 
recovery may result, but later some loss of tissue always 
occurs, and usually with more or less permanent diminution 
of the acuity of hearing. A chronic purulent otitis media 
may follow, or even death as a result of cerebral involve- 
ment, either directly or through mastoid inflammation. 

Treatment. — The local treatment is the same as in acute 
catarrhal otitis media, but if relief from the pain is not ob- 
tained, paracentesis of the membrana tympani is usually 
performed. The use of the cocaine in absolute alcohol and 
aniline will diminish the pain of this procedure, but in 
children or very nervous persons, general anesthesia may 
be necessary. The point of incision should be above and 
posterior to the short process of the malleus, and of such 
an extent as to freely divide the tissues of the inner wall as 
well as of the tympanic membrane. The free hemorrhage 
should be aided by douching with warm water. A free 
catharsis should be induced, preferably with some of the 
salines, before attempting paracentesis. 

Internally, aconite, gelsemium, jaborandi, phytolacca, 
Pulsatilla, and in addition, calcium sulphide to saturation 
should be given. 

If the mastoid is involved, Leiter's coil or the aural ice 
bag may be used continuously for a short period, but if re- 
lief is not obtained within twenty-four hours, it should be 
discontinued. If the mastoid tenderness continues, an op- 
eration is usually necessary. 

After discharge from the tympanum commences, either 
through an artificial incision, or a spontaneous rupture, the 
canal should be kept clean by the use of cotton, drying the 
canal thoroughly, and insufflating boric acid by means of 
a DeVilbiss powder blower. Care must be exercised, as if 
much powder is blown into the ear, it may occlude the open- 



Chronic Purulent Otitis Media. 561 

ing in the membrane and through the pressure exerted, 
cause serious complications. Simply a light dusting of the 
powder is required. If the secretion is purulent, the cal- 
endulated boric acid is preferable. When granulations of 
recent formation are present, the combination with salicylic 
acid, or thuja should be employed. When the secretion is 
scanty, the mucous membrane of the tympanum pallid, the 
iodoform preparation is indicated. 

In but few cases should watery preparations be em- 
ployed, as there is already an excessive amount of moisture, 
and it is practically impossible to thoroughly dry the mid- 
dle ear after irrigation. 

Chronic Purulent Otitis Media. 

Synonyms. — Otitis Media Purulenta Chronica. Chronic 
Suppurative Inflammation of the Middle Ear. 

Etiology. — -This condition may follow an acute catarrhal 
or an acute purulent inflammation of the tympanum, and 
in some cases, especially tubercular, it may appear without 
any premonitory symptoms, being chronic in character 
from the beginning. When the result of a pre-existing mid- 
dle ear affection, and the discharge has continued for three 
months, the term chronic is usually rightly given. 

Pathology. — In all of these cases there is more or less 
necrosis of tissue. It begins usually in the mucous or con- 
nective tissue, and in a short time attacks the bony struc- 
tures. The incus is most often first affected when the bony 
necrosis begins with the ossicles. The inner tympanic wall 
is infrequently affected unless the suppurative process is of 
tubercular origin, or a complication of an acute infectious 
disease. There is more or less destruction of the membrana 
tympani, but it is seldom that the entire membrane is de- 
stroyed, sometimes there may be only the rim of the mem- 
brana vibrans left. Perforation may occur in any portion 
36 



562 Nose, Throat and Bar. 

of the membrane, but is most frequently found in the pos- 
terior or postero-inferior quadrant. 

The labyrinth is not often affected in chronic suppura- 
tion, but it is sometimes present as a result of the acute 
stage. Infrequently the entire labyrinth is destroyed b) 
the suppurative process, and when it is, there is nearly al- 
ways an extension of the inflammatory condition to the 
cranial cavity. 

The most serious complication in chronic suppuration 
is the liability of extension of the process to the mastoid. 
This does not often occur if there is free drainage through 
the external canal, but obstruction, through any cause, of a 
free exit for the purulent material, may force it backward 
into the mastoid cells, resulting in an osteitis with more or 
less destruction of the bony structure. 

A chronic inflammatory action of the mastoid is prac- 
tically always present in chronic suppurative middle ear 
disease, and consists in a chronic proliferation of the bony 
tissue, eventually obliterating the pneumatic spaces, the en- 
tire process becoming a dense eburnated bone. In these 
cases an acute inflammatory condition of the tympanum is 
much more liable to extend to the cranial cavity than where 
the mastoid spaces are open. 

Cholesteatoma may develop from a chronic suppuration 
of the middle ear, provided the inflammatory action as- 
sumes a type of rapidly formed and rapidly desquamated, 
superficial mucous epithelium, with very little or no fluid 
inflammatory products. If not removed the masses grad- 
ually increase in size, dilating and causing absorption of 
the surrounding tissue. 

Symptoms. — Often the only symptom is the constant 
purulent discharge from the ear, but the amount may be so 
slight as to be found only on inspection. The hearing is 
more or less impaired, but is not proportionate to the ex- 
tent of the morbid condition. Tinnitus is more infrequent 



Chronic Purulent Otitis Media. 563 

than in chronic otitis media. Vertigo may occasionally be 
complained of, and vary in severity. The discharge from 
the ear is not necessarily continuous, as it may be lacking 
for weeks, or even months, depending upon the character 
of the morbid process. In some cases the discharge appears 
only during or following an acute rhinitis or nasopharyn- 
gitis. 

Necrosis of the bony structures is usually present in 
those cases showing granulation tissue in the tympanum, 
especially where the ear has been kept comparatively free 
from discharge. The odor in bony necrosis is character- 
istic. In some cases the amount of the discharge is so 
slight that it simply remains within the canal, where it dries, 
forming crusts upon the posterior or superior walls, and 
may spread downward close to the membrana tympani, con- 
cealing it more or less. Implication of the labyrinth is 
nearly always present in cases of long standing. 

Diagnosis. — This is made by inspection of the ear, the 
history, and also by a functional examination. The use of 
a probe and also Siegel's otoscope will give much informa- 
tion regarding the condition of the membrana tympani and 
the mucous lining of the tympanum. 

Prognosis. — This will depend upon the cause, the ex- 
tent of the morbid process and the general condition of the 
patient. Regarding improvement in hearing, this should 
be guarded, as in many cases there is but little change in 
the acuity of hearing. In some cases the hearing ma)' ap- 
parently reach the normal, but they are the exception. 

Treatment. — This is necessarily local and constitutional. 

Local. — Cleanliness is of the utmost importance, and 
this is best secured by the use of cotton on a cotton carrier. 
The use of fluids is to be condemned in the majority of 
cases. There is always an excess of moisture and it is prac- 
tically impossible to thoroughly dry the ear after syringing. 
With cotton the ear can be cleansed of such secretion as is 



564 Nosk, Throat and Ear. 

within reach, then an insufflation of powder will be prefer- 
able to the pernicious habit of syringing. Only infrequently 
will the air bag be required. Polypi should be removed 
with the snare or curette. Exuberant granulations may 
be present, and must be destroyed by the use of some agent. 
If the corrosive acids are employed they can be readily 




FiG. 105. Wilde's Polypus Snare. 



applied by means of a broom splint, cut squarely across the 
end and dipped into the acid. After a few moments there 
will be sufficient material in the pith of the splint to do the 
work, and by wiping the splint with cotton, any excess of 
acid is removed. 

The powders most frequently employed are boric acid, 
calendulated boric acid, carbolized boric acid 5 per cent, 




2^ 



MAX WOCHER & SON, OIN., O. 




Fig. 106. DeVilbiss Powder Blower. 

ergotized boric acid, boric acid and thuja, boric acid and 
salicylic acid, boric acid and iodoform, but in some cases 
other combinations may be required. Powders should be 
more or less soluble, and should never be packed in the 
canal. The favorite blower is the DeVilbiss, which throws 
the powder in a fine cloud, and does not pack it in masses. 



Otitis Media Purulenta Residua. 565 

In some cases it is necessary to use a liquid preparation 
to reach the attic or tympanic portion of the Eustachian 
tube, and thuja, or Lloyd's hydrastis is most frequently em- 
ployed. The use of hydrogen peroxide is seldom beneficial 
and there is always danger of its forcing some of the mor- 
bid material into the mastoid spaces. 

Internally the drugs most frequently employed are cal- 
cium sulphide, silicea, gold and sodium chloride, potassium 
bichromate, phytolacca, hydrastis, pulsatilla and hamamelis. 

Otitis Media Purulenta Residua. 

Under this title is included the sequelae of a purulent 
otitis media, where permanent changes or destruction of 
tissue occurs. Two classes of cases are found, the acute 
or sub-acute, and the chronic. 

Acutk or Subacute. 

Etiology. — In this class the exciting cause of the symp- 
toms is usually an acute rhinitis or nasopharyngitis. Epi- 
demic influenza may also be a factor. The employment of 
artificial aids to hearing, improper methods of cleansing 
the external auditory canal or the development of asper- 
gillus in the canal may also be exciting causes. 

Pathology. — This varies according to the course of the 
original lesion, but often there is a similar condition to that 
found in acute catarrhal otitis media, or tubo-tympanic con- 
gestion. There may be a serous discharge passing through 
a perforation in the membrane into the canal, but if the 
membrane is intact, this secretion collects in the tympanic 
cavity and may be retained for some time, or may escape 
through the Eustachian tube. If infection occurs, a chronic 
purulent otitis media results. 

Symptoms. — When much of the membrane is destroyed, 
there is often some impairment of hearing and tinnitus. The 
presence of secretion in the canal is the most marked symp- 



566 Nose, Throat and Ear. 

torn. Pain is infrequent, and the condition is found oftener 
in children than in adults. Facial paralysis frequently 
occurs. 

Diagnosis. — On inspection, if the membrane is perfor- 
ated, the mucous tissue of the tympanum appears red and 
velvety, and covered with a clear, watery or opaque secre- 
tion. The existing membrane is thickened, turgescent and 
edematous. The upper wall of the canal may be pendulous, 
almost obstructing the lumen of the canal, and making it 
difficult to inspect the tympanum. Pressure with a probe 
may crowd this protruding mass aside. It presents some 
of the characteristics of granulation tissue, but is too dense 
and firm for true granulation tissue. Pressure produces 
considerable pain, but there is not much bleeding under 
probe manipulation. 

Prognosis. — Favorable if the discharge is the only 
symptom, as this frequently ceases spontaneously. Occa- 
sionally infection occurs and a chronic purulent condition 
results. If there is much pain, a cellulitis is present and 
this is always an unpleasant complication. 

Treatment. — This is practically the same as in acute sup- 
purative otitis media. 

Chronic Typ£. 

Etiology. — In this class the changes are the result of 
chronic inflammatory action, and the insidious character 
of the condition usually is not such as to direct the pa- 
tient's attention to the ears until very marked symptoms 
are manifested. Sclerotic changes in the tympanum, es- 
pecially of the ossicles, is usually a feature of this type. 

Pathology. — The perception of aerial vibrations is much 
reduced, and may be due to any one of five conditions. ( I ) 
Edema of the mucous membrane. (2) Circumscribed hyper- 
trophy. (3) Adhesions of the articulations of the ossicles 
or of the malleus or incus to the inner wall of the tvm- 



Chronic Catarrhal Otitis Media. 567 

panum. (4) Bands of cicatricial tissue in the membrane. 
(5) Adhesions confined to the stapes or its immediate re- 
gion. One or more of these conditions may be present. 

Symptoms. — More or less impairment of the hearing- is 
usually present, and is more marked when it follows the 
nonsuppurative form than in the purulent suppurative type. 
Vertigo may occur, especially following some manipulation 
about the ear, either in examination or syringing. The 
acuity of hearing is usually not variable. Cholesteatoma 
may develop. 

Dia gliosis. — This must be made practically by the func- 
tional examination, as inspection does not reveal the 
changes which have occurred. Bone conduction is in- 
creased, the lower tone limit for musical sounds is raised, 
and the upper tone limit reduced. Conversational tones are 
less distinct than sharp metallic sounds. If the labyrinth is 
affected, the upper tone limit is usually much diminished. 

Prognosis. — Usually more favorable than any other 
form of chronic inflammation of the middle ear. 

Treatment. — Hygienic measures are necessary, and any 
abnormal conditions existing in the upper respiratory tract 
should be corrected. The local and internal medication is 
practically the same as given under suppurative otitis 
media. Operative measures are sometimes required, but 
should only be attempted by a specialist. 

Chronic Catarrhal Otitis Media. 

Synonyms. — Otitis Media Catarrhalis Chronica. Chronic 
Xon-Suppurative Otitis Media. Chronic Xon-Suppurative 
Catarrh of the Middle Ear. 

It is unfortunate that the term catarrh is applied to this 
form of ear disease, as it is a misnomer. There are two 
types of this condition, the hypertrophic and the hyper- 
plastic, and the changes which occur in the tympanic tis- 
sues are very different in the two forms. 



568 Nose, Throat and Bar. 

Chronic Hypertrophic Otitis Media. 

Etiology. — This may result from an acute catarrhal 
process in the tympanum ; from an acute congestion of the 
Eustachian tube, and sometimes, so far as a history is con- 
cerned, as an idiopathic condition. Frequent attacks of 
rhinitis or rhino-pharyngitis are common factors, and a 
moderate amount of adenoid growth, although not suffi- 
cient to cause obstruction of nasal respiration, may pro- 
duce venous engorgement, which interferes with the tym- 
panic circulation and eventually produces hypertrophy of 
the tissue. Exposure to climatic changes renders one more 
liable to this condition. Between the ages of fifteen and 
thirty-five, the process is most frequent. A subnormal con- 
dition of the system from any cause may be a factor. 

Pathology. — There is the usual change found in mucous 
membrane where tissue hypertrophy occurs. In the mem- 
brana tympani the mucosa is thickened, the fibrous layer 
swollen, a true hypertrophy resulting. In the later stages 
there is a deposit of lime salts in the membrane. The mem- 
brane varies in appearance, some portions seeming thicker, 
while other parts appear thinner than normal. The tissue 
of the Eustachian tube is thickened and free ventilation of 
the ear does not occur. Retraction of the membrana tym- 
pani results, and increases the local inflammatory condition. 
The changes which take place in the intratympanic struc- 
tures are usually sufficient to cause more or less permanent 
impairment of hearing. The hypertrophic process may 
change to a hyperplastic condition and a dense fibrous tis- 
sue result. 

Inner ear complications are infrequent in the hyper- 
trophic type. 

Symptoms. — Both ears are usually affected, but infre- 
quently to the same extent. The hearing is impaired, and 
is intermittent in the early stages, but the diminution grad- 
ually becomes permanent. Tinnitus is an annoying symp- 



Chronic Hypertrophic Otitis Media. 569 

torn, and is increased by fatigue, mental exertion, indiscre- 
tions in eating or drinking, and by sudden climatic changes. 
The recumbent position may increase the subjective noises, 
and they may be synchronous with the heart's action. The 
noises are described differently by different individuals, 
and often are unnoticed when external sounds are present, 
but may become painfully noticeable when in a quiet place. 
The acuity of hearing is often better in a noisy location. 
Vertigo may be present, and usually is not severe, but is 
often increased by blowing the nose. Pain is infrequent, 
but when present it usually radiates from the pharynx to 
the ear. 

Diagnosis. — Inspection. — The appearance of the parts 
varies. In the early stages the membrane may not show 
any abnormal condition, or there may be a slight amount of 
retraction. According to Schwartze, hyperemia along the 
manubrium and the supero-posterior border, and especially 
with a reddish reflex from the inner wall of the tympanum, 
indicates an activity of the inflammatory process. The 
membrane seems somewhat thickened and the luster is di- 
minished. There is usually a marked change in the ap- 
pearance of the handle of the malleus as a result of the 
rotation of the entire ossicle. 

In the later stages the retraction is usually very marked, 
and the membrane has an opaque appearance, the light spot 
being displaced, broken or lost. If either auto-inflation or 
Politerization has been followed for some time, there may 
be relaxation of the membrane in the upper and posterior 
quadrant. 

The use of Seigel's otoscope reveals the presence of ad- 
hesions or of a relaxed membrane. 

Functional Examination. — There is diminished activity 
of hearing for conversational tones, but whispers are often 
heard better than ordinary tones. The upper tone limit 
may be normal or diminished. In the early stages, bone 



57^ Nos£, Throat and Ear. 

conduction is increased, and the tuning fork is heard best 
in the ear most affected, but the reverse is often true in the 
later stages. 

Prognosis. — This depends upon the cause and also the 
stage of the condition. In early stages, if dependent upon 
nasal or nasopharyngeal lesions, the prognosis is favorable, 
provided these are corrected. In atrophic conditions of the 
nasal or pharyngeal tissues, provided the process has not 
gone too far, relief may be obtained. The treatment must 
extend over a considerable period of time, however. Proper 




Fig. 107. Siegel's Otoscope. 

hygienic measures must be insisted upon, and this includes 
dietary regulation. In cases of long standing, the condi- 
tion of the labyrinth must be considered in giving a prog- 
nosis. 

Treatment. — The upper respiratory tract should be 
placed in as nearly a normal state as possible. If operative 
procedures are required, it should be done at once. Local 
treatment is usually of little avail, the use of proper in- 
ternal medication being of most value. The drugs usually 
indicated are phytolacca, iris, jaborandi, cimicifuga, 
bryonia, Pulsatilla, gelsemium, potassium bichromate, po- 



Otosclerosis. 571 

tassium iodide, acid hydrobromic dil, and occasionally col- 
linsonia. 

Chronic Hyperplastic Otitis Mkdia. 

Etiology. — This condition may result from the hyper- 
trophic form ; follow a purulent otitis media ; or be idio- 
pathic. In the latter type it may result from a severe ill- 
ness or a subnormal condition of the system. Females seem 
to be most often subject to this form of chronic otitis media. 
The condition may. be bilateral, and heredity appears to be 
a factor, especially in neurotic individuals. Hyperplastic 
inflammation is most often found between the ages of forty 
and fifty, but may occur prior to this, but seldom is found 
after fifty years of age. 

Pathology. — This is very similar to the hyperplastic 
changes occurring in mucous membrane in other regions. 
The changes are usually more pronounced near the* oval or 
round windows. The bony structures are often involved, 
as well as the connective tissue. The labyrinth is frequently 
affected, and often in the early stages. The tissues of the 
Eustachian tube are affected, and in the later stages, an 
excessive opening of the canal is usually present, and 
atrophy of the muscles controlling the tube occurs. 

Otosclerosis, Rarefying Osteitis of the Labyrinthine 
Capsule. 

Besides the secondary changes in the labyrinth due to 
middle ear conditions, bony tissue may develop in the imme- 
diate vicinity of the oval or round windows. The growth 
may be in the vestibule, the stapedio-vestibular ligament, 
the foot plate of the stapes, the ligament or oval window. 

Symptoms. — In the early stages the symptoms are so 
slight as to be ordinarily ignored. Tinnitus is usually pres- 
ent, and is more noticed than the impairment of hearing. 
Dizziness may be complained of, and intermittent neuralgic 



572 Nose, Throat and Ear. 

pain may be present. Headache and hebetude sometimes 
result from the condition. In the later stages the im- 
pairment of hearing is much increased, and is especially 
noticeable when the acuity of hearing is being tested. Later 
the tinnitus often becomes less annoying, or may entirely 
disappear. 

Diagnosis. — Inspection does not always show a change 
in the appearance of the membrane, especially when the con- 
dition has been sclerotic from the start. If there is con- 
siderable retraction of the membrane the hypertrophic type 
has usually preceded the hyperplastic changes. In some 
cases there is a thinning of the membrane and in the later 
stages the membrane is often of a dead white color, due to 
atrophic changes in the fibrous layer. The membrana 
flaccida is not often changed in appearance when the process 
starts as a hyperplastic condition, but it usually presents a 
crumple'd appearance if hypertrophic changes preceded the 
hyperplastic. 

Functional Examination. — The acuity of hearing is im- 
paired for both conversational and whispered tones. For 
the acoumeter or watch the diminution varies according to 
the extent of involvement of the labyrinth. Bone conduc- 
tion is increased if the tympanum only is affected. 

Prognosis. — In this form the prognosis is unfavorable, 
although the condition may remain passive for a consid- 
erable time, as there is a decided tendency to increased im- 
pairment of hearing under any form of treatment now 
known. 

Treatment. — The various forms of massage and infla- 
tion have not met with the success expected, and in many 
instances have apparently hastened the morbid process. In 
some cases forcible inflation may break recent adhesions, 
but if the process is of long standing, this is hardly to be 
expected. If more or less absorption of the tissue can be 
obtained, there may be an improvement of the hearing, but 



Otosclerosis. 573 

unfortunately this can seldom be obtained. Occasionally 
the use of jaborandi, pilocarpine, gelsemium, hydrastis, 
Phytolacca, potassium iodide or physostigma, has appeared 
to improve the condition. Surgical measures will some- 
times improve the condition, but should only be attempted 
by the specialist. 



CHAPTER XXX. 
ANATOMY OF THE MASTOID. 

The anatomical relations of the mastoid vary with the 
age and also to a certain degree, with the sex of the patient. 

External Contour. — The mastoid process is located at 
the inferior and external surface of the temporal bone and 
behind the auricle. The usual form is conoidal. The size 
of the mastoid usually is dependent upon the strength of 
the muscles attached to its tip, but there is a more or less 
uniform development until the age of maturity. 

The squamous above and in front, and the petrous be- 
hind and below, practically are the portions of the temporal 
bone that form the mastoid process. The union of these 
forms the squamo-mastoid suture. The squamous portion 
of the mastoid forms a triangle, bounded by the suture, the 
meatus, and the supra-mastoid ridge, which extends be- 
hind the posterior root of the zygomatic process, and is al- 
ways more or less prominent. This important landmark 
is usually located a little below the floor of the middle cra- 
nial fossa, and very seldom above it. Another and an im- 
portant landmark is the spine of the Henle, which is usually 
present. This is a more or less rugose prominence, located 
back of and above the postero-superior quadrant of the 
meatus and below the origin of the supra-mastoid ridge. 
According to O. Lenoir, this spine does not spring from 
the tympanic bone. Prior to four years of age this spine is 
often absent. 

Structure. — The external portion is composed of dense 
bony tissue and the surface is rough, giving attachment to 

574 



Anatomy of the Mastoid. 



575 



various muscles. Numerous foramina are found. The 
thickness of this outer wall varies, being comparatively thin 
in children, but increasing in thickness until adult life, when 
the density and thickness varies considerably. A very dense 
cortex may lead the operator to believe an eburnated process 
is encountered. The cavities in the mastoid are divided into 
the antrum, a constant pneumatic space, and nearly so in 




• Fig. 108. The field of operation. H, the spine of Henle ; c. s. m., 
the supra-mastoid ridge; s. m. s., the mastoido-squamous ridge; 
Iv, the lateral sinus; Cond., the bony meatus; Zyg., Zygoma, and 
Glen., the glenoid fossa. Sty., styloid process. 



its location ; and the cells, which vary in different indi- 
viduals. These cells are divided into the mastoid, petrous, 
and squamous, according to their situation. Zuckerkandl 
has made the division of mastoids into pneumatic, mixed, 
and diploic or sclerosed, according to the prevalence or com- 
parative absence of these cells. In cases of suppurative 
otitis media, a progressive eburnation almost amounting to 



576 Nose, Throat and Bar. 

sclerosis of the mastoid spaces may occur. The true mas- 
toid cells are below an imaginary horizontal line a little 
lower than the junction of the upper third and lower two- 
thirds of the meatus. When well developed these are the 
easiest cells reached in operative procedures, and also dis- 
tinguish between pneumatic, mixed, and diploic mastoids, 
it being impossible to determine this by any external ap- 
pearance. 

The squamous cells are located in the squamous portion 
of the process forming the posterior wall of the external 
auditory meatus. The petrous cells are in the base of the 
process above the line of the junction of the upper and lower 
two-thirds of the meatus and extend behind toward the lat- 
eral sinus. • 

The antrum being the most constant, its study is im- 
portant as regards (a) depth; (b) relation to external land- 
marks; (c) its relation fo adjacent structures which it is 
necessary to avoid in operative measures. 

(a) Depth. — This varies according to the age, as well 
as in individuals. Under one year it is from two to four 
millimeters. Later the depth is increased but not in a regu- 
lar ratio, (b) Position. — In young children the spongy 
spot, located above and behind the meatus covers the an- 
trum, which is easily opened by a curette or bistoury. The 
supra-mastoid ridge, squamoso-mastoid suture, and spine of 
Henle when present, are the landmarks to remember. The 
antrum is practically always below the supra-mastoid ridge, 
above and in front of the squamoso-mastoid suture (Broca). 
The spine of Henle, or if this is absent, the supra-meatal 
fossa which may be only a slight depression, are constant 
guides. 

A canal, the aditus ad antrum, connects the antrum and 
tympanum. In the adult this is approximately three to five 
millimeters long, three millimeters high, and three or four 
millimeters deep. 



Anatomy of thb Mastoid. 577 

(c) Deep Relations of the Antrum and Aditum. — Across 
the roof of the tympanum the aditus is in close relation with 
the cranial temporal fossa and temporal lobe of the brain. 

In operating, the horizontal semi-circular canal, facial 
nerve, and lateral sinus must be remembered. 

The horizontal semi-circular canal is located just be- 
hind the inner wall of the aditus. The protector should be 
against this wall to prevent injury. The rest of the canal 
wall is composed of eburnated bone, and is not liable to in- 
jury. 

The facial nerve leaving by the hiatus Fallopii, passes 
outward about ten millimeters parallel to the axis of the 
petrous bone, then passes vertically downward, leaving the 
cranium at the level of the stylo-mastoid foramen. The 
horizontal portion and the sharp curve of the facial canal 
is protected by a lamella of bone which is occasionally very 
thin. The vertical portion of the canal descends in the 
anterior region of the mastoid, behind the posterior limb 
of the tympanic ring. It passes through compact bony tis- 
sue. In the vertical part the nerve is separated from the 
foramen for the jugular vein by a band of tissue which is 
usually fragile. 

The lateral sinus is the most important, as it is most fre- 
quently injured in mastoid operations. As a rule this sinus 
is so far removed from the site of operation as to be free 
from injury, but through mal-position or careless manipu- 
lation of the instruments, such an accident may occur. 



37 



CHAPTER XXXI. 

INFLAMMATION OF THE MASTOID 
PROCESS AND COMPLICATIONS 
OF TYMPANIC INFLAMMA- 
TION. 

Btiology. — The usual cause of an acute mastoid inflam- 
mation is an extension from the tympanum of an inflam- 
matory process. The causative factor may be either acute 
or chronic, but a simple catarrhal inflammation is seldom, 
if ever, a cause. 

Inflammation of the Mastoid. 

Synonym. — Mastoiditis. 

A primary inflammation is infrequent, but sometimes 
follows a cold, a traumatism, or it may result from a specific 
or turbercular diathesis. In specific infection the usual 
cause is probably the breaking down of a gummatous de- 
posit. Inflammatory action in the external auditory canal 
may implicate the mastoid through contiguity of tissue, es- 
pecially if the posterior wall is affected. Chronic suppura- 
tive otitis media is the most frequent factor of an acute 
mastoiditis. The exanthemata, diphtheria, typhoid, and 
typhus fevers, as well as some pulmonary conditions, may 
be exciting causes. Influenza appears to be a frequent 
cause, probably on account of its affecting the mucous mem- 
branes in nearly all cases. 

Pathology. — In chronic purulent otitis media the lining 
membrane of the mastoid cells is thickened, the vascularity 

578 



Inflammation of the Mastoid. 579 

is increased, and eventually there may be a slight deposit 
of osseous tissue which in some cases, entirely -destroys the 
cells, the mastoid presenting an ivory-like hardness. Ne- 
crotic changes may occur instead of hypertrophic, and if 
free drainage through the tympanum and external audi- 
tory canal is lacking, symptoms of pus retention will be 
present. This may manifest itself by an increased purulent 
discharge in the external auditory canal; or if this is ob- 
structed, through the mastoid cortex, either behind the 
auricle or into the external auditory canal. The pus may 
find an exit through the mastoid in the digastric fossa, or 
it may escape through the roof of the antrum, or the tym- 
panic vault into the middle cranial fossa. Occasionally it 
may pass into the posterior cranial fossa by penetrating into 
the groove of the lateral sinus. 

If the pus enters the cranial cavity, a circumscribed or 
diffuse meningitis results, and an epidural abscess is formed 
in the former condition. Thrombosis of the lateral sinus, 
or a cerebral abscess may also result from this complication. 

Symptoms. — Severe pain over the mastoid, especially 
over the antrum and at the tip, and the pain radiating to 
different parts of the head and face is complained of. The 
pain is most severe at night, and is deep-seated and per- 
sistent. The pulse and temperature are not always indi- 
cations of the severity of the process. Edema of the tissue 
covering the mastoid is more characteristic of an inflamma- 
tion within the canal, than of mastoid complications. Tume- 
faction behind the auricle is infrequent except in , child- 
hood. Fluctuation of these tissues is an evidence of spon- 
taneous rupture of the mastoid purulent material. 

When intracranial complications occur, the symptoms 
depend upon the region affected. If an infectious throm- 
bosis is located in one of the larger venous sinuses there is a 
sudden elevation of temperature, sometimes reaching 105 ° 
Fahr. This lasts but a few hours, the temperature dropping 



580 Nose, Throat and Ear. 

to normal or even 'subnormal. These changes are inter- 
mittent, but may follow in such rapid succession as to be 
unrecognized, or there may be quite an interval between 
the changes. After the onset of fever, there is profuse per- 
spiration and later septic conditions are usually present. 
The patient is weak ; the skin a dull, ashy hue ; pulse weak, 
and a decided mental dullness, or even coma, showing a 
general septic condition. 

If a diffuse meningitis develops from intracranial 
implications, there is severe headache, photophobia, nausea, 
and vomiting, and a constant high temperature. The base 
of the brain is usually involved in these cases, and the pulse 
is rapid. Paralysis of the muscles controlled by the third 
and sixth nerves soon follows as a rule, and rigidity of the 
muscles of the neck is an early and characteristic symptom. 

Diagnosis. — The most positive symptoms of mastoid de- 
velopment are tenderness on deep pressure over the mas- 
toid, and a bulging of the supero-posterior canal wall close 
to the tympanic ring. The directions already given for de- 
termining whether the tenderness or pain is in the external 
auditory canal, tympanum or mastoid, must be remembered. 
Pressure over the tip of the mastoid will cause a sensation 
of tenderness even in normal individuals, hence great care 
is necessary in forming an opinion from this manipulation. 

Prognosis. — Always guarded, but the exciting cause, 
age of the patient, and the general condition must be con- 
sidered. In children, when mastoid complications follow 
the acute infectious diseases, the prognosis is usually un- 
favorable. In adults the prognosis is usually good, unless 
it is a complication of a chronic suppurative otitis media 
of long standing. 

Treatment. — If in the early stages, and unless there are 
urgent symptoms presenting, an effort should be made to 
abort the condition. Absolute rest, a light diet, and a saline 
cathartic are important aids. If a suppurative otitis media 



Inflammation op the Mastoid. 



58i 



is present, free drainage is necessary, and the opening in 
the membrana tympani may have to be enlarged, this should 
be done by means of a probe pointed knife. The canal and 
tympanum should be kept as free from discharge as possible, 
but syringing or the use of hydrogen dioxide is to be con- 
demned. Leiter's coil for the application of cold is often 
beneficial and may be used for twenty-four hours, but 
should not be employed for a longed period. 

Internally. — The use of the remedies advised in acute 





Fig. 109. Mastoid Instruments. 



FiG. 1 10. Mastoid Retractor. 




1 » 



FlG. hi. Mastoid Curettes. 



catarrhal otitis media or in the suppurative form should be 
employed. 

In the acute condition where relief is not obtained within 
seventy-two hours, operative measures are required. In 
the chronic type it is not usually necessary to resort to rad- 
ical measures so soon, as proper internal medication will 
often relieve the condition, and calcium sulphide or silicea 
are usually indicated. 

Operative. — The complete operation is the most effica- 
cious, but should not be attempted excepting by a surgeon 



5^2 



Nose, Throat and Bar. 



of experience. The instruments required for the operation, 
besides a razor for shaving the head, are scalpels, artery 
clamps, periosteotome, scissors straight and curved on the 
fiat, retractors, chisels and gouges, mallet of wood or lead, 




Fig. 112. Visible landmarks after the incision 

and turning forward of the auricle (Pav.) 

Lettering as in Fig. 108. 



dressing forceps, probes, rongeurs, curettes, ear syringe, 
needles, etc. 

The Operation. — The incision of the skin should begin 
about half an inch below the tip of the mastoid and be car- 
ried upward, following the curve of the auricular attach- 



Inflammation of the Mastoid. 



533 



ment and about one-fourth inch behind it to a point over 
the superior portion of the auricle. A transverse incision 
passing backward, commencing at the base of the mastoid 
will give additional room. The incision should divide the 
tissues and periosteum. This will divide the posterior auric- 
ular artery and its branches, but the hemorrhage is of lit- 
tle consequence. The periosteum should be raised so the 





f ,;*■' 


.. ^ 






Pav.-i 


m. 4 






_:.I1 












Jtg^'^dK-Conxl-. 






\ ; •'•■■■%'■ 














• 





Fig. 113. Showing oblique position of chisel in 
completing and removing the square of cor- 
tex. Lettering as in the previous figures. 



landmarks are revealed. The artery forceps can now be 
applied, and are also aids in retracting the tissues. 

In the adult the field of operation is about three-eighths 
of an inch square. A chisel of this width is held perpendicu- 
larly to the bone three-sixteenths of an inch behind the 
meatus, marked by the spine of Henle, parallel to the cir- 
cumference of the meatus. Two or three sharp strokes of 
the mallet should cause the chisel to penetrate a little over 
one-sixteenth of an inch into the bone. The upper border 
should be just under the supra-mastoid ridge, and the lower 



5*4 



Nose, Throat and Ear. 



border at the lower end of the initial cut. The posterior 
side of the square is the dangerous portion and the chisel 
should be held at an angle of about forty-five degrees. The 
use of the mallet will now remove the square of bone. 

In rarefying osteitis, the antrum will be readily reached, 
but frequently it is necessary to go deeper. This should be 



: 
Paa—l s ' 




,"JS& 






S 


\ 






Cond. • 1 


\ 






IM 







Fig. 114. Showing position of protector (Prot.) 

and of chisel (I) perpendicular to the bone, 

chisel (II) obliquely for the removal of 

the outer attic wall and to make 

the complete operation. Same 

lettering as in previous cuts. 



done carefully, and in those cases where eburnation has oc- 
curred, the work must be cautiously performed. 

In children under the age of ten, the curette and hand 
gouge are usually all that are required, as the bone is soft 
and spongy. 

In nearly all cases after the antrum is located and the. 
mastoid excavated, the bony wall separating the antrum and 



Inflammation of the Mastoid. 



583 



external auditory canal should be removed, making but one 
cavity of the mastoid and tympanum. This may be re- 
moved by the rongeur forceps or by the chisel. A Stacke 
protector should be employed to guard the semicircular 
canal and facial nerve. After all the structures are exposed, 
the cavities should be smoothed, necrosed tissue removed, 
granulations curetted and fistulous tracts excised. 





















A 








/ 


\ 1 ' 






•- «— «« 








Z7 J^^KSk 






mipk" Ad ' 


GLerv^% 






~& ■- Cell, 


atui-T 


V m- 






siyi^r 


• 







Fig. 115. Complete opening of the mastoid cells 

{Cell.), the aditus (Ad.), and of the tympanum. 

The other lettering as in figure 108. 



After the morbid tissue has been cleared away, the 
hemorrhage controlled, and the cavities thoroughly cleansed 
with some solution, the cavity should be dried with gauze 
sponges. After the tissues are partially sutured, a pack- 
ing of gauze should be used to fill the Cctodty, and also some 
placed in the external auditory canal. The traumatism 
should be covered with a gauze pad, and held in position 




FlG. 116. Sclerosed mastoid (right). Lateral sinus (L) in 
close proximity to field of operation. 




FlG. 117. Mastoid, left side. The antrum opened at a depth of 

25 millimeters following the direction of the pin. The 

lateral sinus (L,) 8 millimeters back of field. Wall of 

aditus removed. 

586 



Inflammation of the Mastoid. 587 

by a bandage which does not compress the auricle against 
the side of the head. 

The after treatment does not vary especially from that 
of any operative procedure of a similar character. 

In some cases it will be necessary to open into the cranial 
cavity, but the methods required are usually fully described 
in works on surgery. 



CHAPTER XXXII. 

INTRACRANIAL COMPLICATIONS OF 
TYMPANIC INFLAMMATIONS. 



Otitic Meningitis. 

Either directly from a suppurative process in the tym- 
panum, or by involvement of the mastoid, the meninges 
may be implicated. This may result by the extension of 
bony caries, thinness of the bony walls which are perforated 
by numerous foramina, or by infection through the vessels 
communicating with the cranial fossa. 

Symptoms. — There is usually a constant, high tempera- 
ture ranging from 101 degrees to 105 degrees Fah. In- 
tense headache, nausea, and vomiting, photophobia and 
localized or general convulsive symptoms. In children, 
general convulsions often occur with the high temperature. 
If the basilar meninges are affected, the Cheyne-Stokes 
respiration soon occurs. Delirium is frequently present in 
children, but in adults this is not so often present, and may 
not be present at all, the patient gradually passing into a 
comatose state before death results. 

In serous meningitis, paralytic and convulsive symptoms 
are seldom prominent. The temperature is less than in the 
purulent form, infrequently being more than 103 degrees. 
A diffuse or localized headache is the most marked 
symptom. Delirium is usually slight, but it is diffi- 
cult for the patient to concentrate the mind for any 
length of time. Divergent strabismus is sometimes pres- 

588 



Sinus Thrombosis. 589 

ent as a result of local paresis. Choked disk or a slight 
swelling of the optic papilla is usually found. 

Diagnosis. — Should be by exclusion. The symptoms de- 
scribed should be carefully considered. In children the ex- 
clusion of an acute infectious condition or gastro-intestinal 
wrongs are necessary, as they often produce the same line 
of symptoms. The cessation of a discharge from the mid- 
dle ear coincident with the described symptoms ; tonic 
spasm of certain muscles controlled by the third, fourth, and 
sixth nerves ; choked disk ; photophobia ; respiratory dis- 
turbance and later coma, should confirm the diagnosis. 

Prognosis. — Usually fatal, although Mace wen and 
Dench have operated with successful results in a few cases. 

Treatment — Early surgical measures. 

Sinus Thrombosis. 

In acute or chronic otitis media, an infectious throm- 
bosis of one of the large intracranial venous sinuses may 
occur as a complication. The peculiar relation of the tym- 
panum and mastoid to the cranial cavity and the easy access 
to the cranial structures through the mastoid vein, makes it 
comparatively easy for septic material to be carried to the 
lateral sinus. When such a condition occurs, secondary 
purulent areas may be found in other viscera, the lungs 
especially appear to be a favorite site, septic pneumonia re- 
sulting. 

Symptoms. — Frequently no symptoms are noticed until 
the later stages. A characteristic symptom is a sudden ele- 
vation of temperature, sometimes to 106 degrees, followed 
by a return to the normal or nearly so. After a time gen- 
eral septic conditions are noted. In uncomplicated cases 
cerebral symptoms are usually absent. If cerebral symp- 
toms are present in connection with suspected sinus throm- 
bosis, the probability of cerebral lesions, or an extensive 
secondary meningitis is to be suspected. 



59o Nose, Throat and Bar. 

Diagnosis. — The extreme variations in temperature, 
which should be frequently taken, are usually diagnostic of 
implication of the lateral sinus. Choked disk is confirma- 
tory evidence in cases of suspected sinus thrombosis. The 
development of asthenic conditions without sufficient tym- 
panic or mastoid disturbance to account for this state of 
affairs, is also a symptom. 

Prognosis. — Guarded, although spontaneous recovery 
occasionally takes place. 

Treatment. — Operative measures give the best results. 
The internal medication should be such as will best over- 
come the asthenic condition. 

Extradural Abscess. 

This is really a circumscribed purulent meningitis. The 
meninges are adherent to the inner table of the skull, the 
purulent material being confined to a limited area by the 
adhesion of the membrane to the bone. An abscess be- 
tween the dura mater and inner table is usually a complica- 
tion of a chronic suppurative otitis media or mastoiditis. 
The thin bone separating the middle ear and mastoid from 
the cranial cavity becomes necrotic, and a localized low 
grade of meningitis results. Such a condition does not 
occur when the process is acute in character. 

Symptoms. — Pathognomonic symptoms are few. An 
intense, constant, localized headache, and elevation of tem- 
perature, seldom if ever 102 degrees, are practically the 
only symptoms which point to the character of the lesion. 
If the process is in the cerebellar fossa, there may be ver- 
tigo and vomiting. In the latter stages, no matter where the 
lesion is located, there is hebetude, probably from effusion 
into the ventricles. 

Prognosis. — Eventually fatal, unless recognized early 
and operative measures are promptly employed. 



Cerebral Abscess. 591 

Cerebral Abscess. 

A circumscribed purulent area within the brain sub- 
stance may be either acute or chronic in development. The 
former are infrequent. The usual factor in chronic cerebral 
abscess is probably a purulent otitis media. The lesions 
may be single or multiple, and may involve the cortex or 
the deeper portions of the brain, and may be bilateral or 
unilateral. The temrjoro-sphenoidal lobe is oftenest af- 
fected, and the cerebellum is next in frequency. Infre- 
quently a similar process occurs in the medulla. Cerebral 
abscesses are usually comparatively deep in the brain sub- 
stance, and if not interfered with, often rupture into the 
lateral ventricles. The material in these abscesses is often 
non-infected. 

Symptoms. — These depend upon the location. If the 
process is acute, and the abscess is located so that pres- 
sure is produced upon the motor tract or the motor area 
of the cortex, localized symptoms occur, these being con- 
vulsive in character. In chronic cases convulsive attacks 
are seldom present, paralysis occurring without premonitory 
symptoms. As a result of the usual location of the lesion, 
sensory or motor aphasia occurs in many cases, but may not 
be recognized unless a careful examination is made. 
Agraphia is sometimes present. Localized symptoms are 
occasionally absent, particularly if the lesion is in the right 
hemisphere. The asthenic condition is most important. 
The mental condition is important, as irritability at times, 
and again inattention or even somnolence may be noted. 
Eventually coma supervenes. The temperature seldom goes 
above 99 degrees, and the pulse may be normal or inter- 
mittent. In cases of long standing, a dull diffuse headache 
is often present. Insomnia may be present. 

Diagnosis. — Usually difficult. The symptoms described, 
and sometimes the presence of choked disk may be an aid, 



592 Nose, Throat and Ear. 

but the ophthalmoscopic * picture is not characteristic of 
this lesion. 

Prognosis. — Unfavorable, although surgical measures 
may prove curative if the diagnosis can be made sufficiently 
early. 

Cerebellar Abscess. 

Abscesses in this region are not infrequent, the source of 
infection being either through the labyrinth or the posterior 
wall of the lateral sinus. 

Pathology. — There is a breaking down of the infiltrated 
tissue, pus formation, and an accumulation of fluid in the 
lateral ventricles. The latter condition is important, as the 
symptoms presenting may be due entirely to the dilatation 
of the ventricles. 

Symptoms. — Not always readily recognized. If deeply 
located, the abscess may cause persistent vomiting. Ver- 
tigo and unsteadiness in walking may be present. Usually 
the most prominent symptom is that of intracranial pressure. 
Hebetude, apathy, and sometimes headache may be pres- 
ent. The temperature is slightly elevated, but seldom 
reaches 101 degrees. Nystagmus may occur. 

Diagnosis. — Difficult. 

Prognosis. — Unfavorable unless an early diagnosis and 
| operative measures are instituted in the early stages. 



CHAPTER XXXIII. 

DISEASES OF THE PERCEPTIVE 
APPARATUS. 



General Considerations. 

So many factors may cause disturbance of hearing, and 
the actual lesions of the perceptive mechanism are so ob- 
scure that many of the supposed inner ear conditions are 
simply a matter of speculation. It is a well known fact that 
atmospheric conditions, as well as the general physical or 
nervous condition of the patient, influence audition, and 
also must have some bearing upon the labyrinth and cere- 
bral centers. When cerebral lesions have been present, 
either through infection from middle ear disease or from 
other causes, and the areas of audition have been affected, 
it is not so difficult to make a diagnosis in known cases or 
where an accurate history can be obtained. In the majority 
of cases it is largely a matter of conjecture as to the exact 
morbid state, so far as our present knowledge is concerned. 

Anemia of the Labyrinth. 

Etiology. — This may result from a profuse general 
hemorrhage, caused by a traumatism, an aneurismal rup- 
ture, a uterine hemorrhage following partuition, or of a 
simple or pernicious anemia. 

Symptoms. — In this condition the hearing is impaired 
38 593 



594 Nose, Throat and Ear. 

for sharp sounds and high pitched musical tones. There 
is a lack of nutrition to the labyrinth and the patient has to 
make a special effort to hear. When a number are talking 
it is difficult to follow the conversation. Tinnitus is an- 
noying, and is usually increased upon lying down. The 
sounds are generally dull, low pitched, and synchronous 
with the heart's action. Vertigo may result from any sud- 
den shock to the nervous system, and sometimes there may 
be syncope. The facial expression is sometimes charac- 
teristic, being dull, abstracted, and listless. The general 
symptoms of anemia are also present. 

Diagnosis. — The pallor of the skin, and especially of 
the mucous membranes, is usually marked. An inspection 
of the middle ear seldom reveals any characteristic appear- 
ance. A functional examination reveals a normal lower 
tone perception, and the upper tone limit may be either nor- 
mal or diminished. Bone conduction is usually consid- 
erably reduced. Audition for conversational or whis- 
pered tones is usually somewhat deficient. The pa- 
tient usually repeats the words slowly and hesitat- 
ingly, as though not thoroughly comprehending what has 
been said. The conditions upon which a diagnosis is made 
are absence of an otitis media ; normal tone perception, un- 
less of the upper tone limit ; much diminished bone conduc- 
tion, and the anemic state of the patient. 

Prognosis. — Favorable in acute cases the result of 
hemorrhage, or a simple anemia. Guarded in pernicious 
anemia, as permanent structural changes often occur 
through extravasations within the nerve tissue. 

Treatment. — The drugs most frequently indicated are: 
arsenic in some form, cuprum, hydrastis, jaborandi in small 
doses, physostigma, cactus, Crataegus, strophanthus, glonoin, 
and sometimes the soluble forms of iron. Nux, strychnine, 
or ignatia may be indicated, and pulsatilla is often required. 
Attention to the diet and general hygiene is important. 



Hyperemia of the Labyrinth. 595 

Hyperemia of the Labyrinth. 

Etiology. — This condition may result either from venous 
stasis, or an increased arterial supply. In gouty or rheu- 
matic constitutions such a condition may occur. When the 
vocation requires excessive exertion, exposure to all kinds 
of weather, or through the excessive use of alcoholic stimu- 
lants, changes in the vascular current may result. Sudden 
changes in atmospheric pressure, as passing from a caisson 
to a normal atmospheric condition, or the rapid ascent in an 
elevator or balloon, causes vascular changes. Sudden con- 
densation of air in the external auditory canal, either by a 
blow on the ear or concussion, may also be a cause. 

Pathology. — Overdistention of the blood vessels for 
some time will cause localized dilatation, changing the regu- 
larity of the blood supply. Rupture of the vessels may 
occur through a sudden increase of pressure, apoplectic 
changes resulting. The effusion may be absorbed, or dis- 
integration follow. 

Symptoms. — When the blood supply to the labyrinth is 
excessive, a sensation of fullness and distention in the head 
is present. Giddiness or sometimes vertigo, and tinnitus, 
usually high-pitched, is noticed. The impairment of hear- 
ing is usually slight. If the walls of the vessels are much 
affected, the hearing may be considerably impaired, and all 
the symptoms aggravated. In chronic cases, especially in 
plethoric persons, sudden emotional excitement, overexer- 
tion, indigestion, or even indulgence in alcoholics, will in- 
crease these symptoms. 

Diagnosis. — Inspection of the membrana tympani may 
show an increased vascularity. The functional examination 
shows some lowering of the upper tone limit and a dimi- 
nution of bone conduction. Conversational tones may be 
slightly indistinct. Sharp or shrill sounds may be painful. 
A positive diagnosis is difficult. 



596 Nose, Throat and Ear. 

Prognosis. — In recent cases, and where the hearing is 
but slightly impaired, if rapid absorption of the effusion 
can be obtained, the prognosis is favorable. In cases of 
long standing some relief may follow a persistent course of 
treatment. 

Treatment. — Improvement of the general condition and 
good hygienic measures are important. The drugs most 
frequently required are jaborandi, gelsemium, bryonia, Hy- 
drastis, physostigma, potassium iodide, the bromides, acid 
hydrobromic dil, Pulsatilla, cimicifuga, rhus tox, and occa- 
sionally the saline laxatives, but not often to the point of 
catharsis. 

Labyrinthine Hemorrhage. 

Etiology. — Extravasation of blood from the vessels of 
the labyrinth may result from external causes, as a fall, 
blow upon the head, or the concussion from an explosion. 
Forcible inflation of the middle ear by any method, or severe 
paroxysms of coughing or sneezing may cause hemorrhage. 
It may occur in hemophilia, leukemia, arterial sclerosis, or 
pernicious anemia. Any effort which may produce venous 
congestion may also be a cause. In cerebral hyperemia it 
may also be a complication. 

Pathology. — Extravasation of blood in the labyrinth 
produces the same changes as occur with a similar lesion 
elsewhere. The amount of the effusion and the resulting 
condition determines whether there will be any improve- 
ment or not in the functional activity of the structure. 

Symptoms. — These vary according to the severity of 
the hemorrhage. Vertigo is usually marked, the patient 
often falling prostrate. Nausea, tinnitus, and a sudden 
diminution of hearing, are the characteristic symptoms. A 
functional examination is the only method. The impaired 
hearing for any sound, and the reduction of bone conduc- 
tion are important symptoms. The lower portion of the 
labyrinth is most frequently affected, and the lower tone 
limit may not be much reduced. 



Specific Inflammation of the Labyrinth. 597 

Prognosis. — If but a limited area is affected, sponta- 
neous recovery may follow. Some improvement in the 
hearing usually follows in all cases. 

Treatment. — The patient should be kept as free from ex- 
citement as possible, and any exertion should be prohibited. 
Free catharsis is usually of value in the early stages of the 
condition. Loud noises should be avoided. Internally the 
use of jaborandi, gelsemium, bryonia, asclepias, pulsatilla, 
or potassium iodide are most generally indicated. 

Labyrinthine Embolism and Thrombosis. 

Etiology. — Either condition is infrequently met with. 
Thrombosis may result from a severe otitis media, espe- 
cially following the exanthemata. 

Pathology. — The occlusion of a small arterial branch 
causes an anemia of the affected area. Disintegration fol- 
lows if a collateral circulation does not occur, or the circu- 
lation is not re-established. A venous thrombosis, unless 
infected, is unimportant. 

Symptoms. — These are practically those of labyrinthine 
hemorrhage, only less marked. The abrupt development 
of tinnitus is probably the most constant symptom. The 
hearing may be practically normal. 

Prognosis. — Guarded.. 

Treatment. — Jaborandi, potassium iodide, hydrobromic 
acid dil., nux vomica, and pulsatilla are most frequently 
indicated. 

Specific Inflammation of the Labyrinth. 

Etiology. — The labyrinth is not infrequently affected in 
either acquired or hereditary syphilis. In the former class 
the affection is usually a late manifestation, seldom occur- 
ring during the secondary stage. In the hereditary form 
interstitial keratitis is often associated with the aural con- 
dition. 



598 Nosk, Throat and Kar. 

Pathology. — The changes which occur are those' of a 
chronic inflammatory action. Specific lesions of the vessels 
are obliterating endarteritis, as well as those found in the 
blood vessels of other regions. There is often the forma- 
tion of new bony tissue, which narrows the lumen of the 
semicircular canals. In hypertrophic conditions within 
the vestibule there may be a deposit of bone about the oval 
window, causing a thickening of the foot plate of the stapes, 
or synostosis of the stapedio-vestibular articulation. 

Symptoms. — There is usually a sudden and marked im- 
pairment of hearing, and an annoying tinnitus in the ac- 
quired form. In the hereditary type the hearing is usually 
progressively diminished and associated with interstitial 
keratitis. 

Diagnosis. — In the adult the sudden attack is character- 
istic. In the hereditary form the general appearance of the 
patient should direct attention to the probable cause. A 
functional examination usually reveals only a slight change 
in the lower tone limit. The upper tone limit is much re- 
duced, especially for sharp metallic sounds. Bone conduc- 
tion is much diminished or entirely lacking. 

Prognosis. — Usually unfavorable, but treatment should 
be continued for a considerable period. 

Treatment. — This should consist of internal remedies. 
Jaborandi, bryonia, phytolacca, iris, hydrastis, potassium 
iodide, and mercury in small doses are the most frequently 
indicated drugs. Occasionally nux or strychnine may be 
of value. 

Secondary Inflammation of the Labyrinth from a 

Chronic Suppurative or Non-Suppurative 

Otitis Media. 

A long continued morbid process in the tympanum is 

very liable to cause changes in the labyrinth, either from 



Secondary Inflammation of the Labyrinth. 599 

the pressure exerted against the exposed structures of the 
inner ear; through disuse of the auditory nerve filaments, 
or by extension through contiguity of structure. 

.Symptoms. — It is difficult to determine positively be- 
tween tympanic and labyrinthine changes. All the symp- 
toms are such as should be ascribed to the perceptive por- 
tion of the ear, and it is practically impossible to determine 
the exact condition. Tinnitus is practically always present 
in these cases, but it is intermittent as a rule, and usually is 
most annoying when in the recumbent position. In neurot- 
ics any form of exertion increases the noises. If the laby- 
rinth immediately related to the semicircular canals is af- 
fected, or the canals themselves are invaded, vertigo is a 
frequent symptom. 

Diagnosis. — Inspection of the ear shows but little varia- 
tion from what is ordinarily found in the same class of cases 
where the inner ear is not affected. The primary lesion not 
giving a different picture as a result of the labyrinthine 
lesions. The functional examination shows impaired audi- 
tion for practically all sounds, The lower tone limit is 
raised and the upper tone limit reduced, depending upon 
the involvement of the labyrinth. 

Prognosis. — Usually unfavorable, although in some 
cases considerable improvement may follow a protracted 
course of treatment. 

Treatment. — Morbid tympanic conditions must be reme- 
died, and for these changes either operative or medicinal 
measures may be required. If the former, the work should 
only be attempted by a surgeon familiar with the anatomy 
of the parts. Medicinal treatment must be continued for a 
protracted period, and the drugs usually required are 
jaborandi, hydrastis, bryonia, cimicifuga, pulsatilla, hydro- 
bromic acid dil., potassium iodide, or mercurials. 



600 Nosk, Throat and Ear. 

Acute Labyrinthine Inflammation Secondary to Acute 
Purulent Otitis Media. 

Etiology. — This condition is usually the result of a mid- 
dle ear affection following the exanthemata. It is most 
often found in children, and usually only in severe types 
of these diseases. 

Pathology. — Panotitis is the term often employed for 
this condition. There is usually a rapid breaking down of 
the softer tissues and a caries of the bony structures of the 
tympanum. The labyrinth is affected either directly through 
the bony wall or through the oval or round windows. The 
morbid changes in the labyrinth are similar to those of the 
tympanum. 

Symptoms. — There is usually considerable systemic in- 
fection, and in those old enough to intelligently answer 
questions, vertigo and an intense tinnitus as well as consid- 
erable impairment of hearing, or even complete loss of audi- 
tion are complained of. When the inner wall is affected in 
this manner, facial paralysis frequently occurs. Sometimes 
the petrous portion of the temporal bone is more or less af- 
fected, and a sequestrum of considerable size may be found. 
In these cases there may be a profuse hemorrhage from 
the ear, and if either the internal carotid artery or internal 
jugular vein are eroded, the hemorrhage is usually fatal. 
Meningitis is a frequent complication in these cases. 

Diagnosis. — An inspection of the ear gives little infor- 
mation, excepting the presence of a severe suppurative otitis 
media. In the later stages exuberant granulations may be 
present in the tympanum, and careful manipulation with a 
probe may reveal denuded areas of the inner tympanic wall. 
The characteristic odor of bony necrosis is usually present, 
but an offensive odor is not always positive evidence of 
bony necrosis. A functional examination in very young pa- 
tients is impossible, but when old enough to answer intel- 



Acutk Labyrinthine Inflammation. 6oi 

ligently it will be found that bone conduction is much im- 
paired or destroyed. The upper tone limit is reduced to 
not over two thousand vibrations per second, while low 
tones are fairly well heard. 

Prognosis. — Unfavorable in the majority of cases, both 
as to restoration of function and also as regards life. 

Treatment. — As thorough cleansing of the ear as possi- 
ble is important. Internally the use of silicea, lime in some 
form, gold and sodium chloride, potassium bichromate, or 
hydrobromic acid dil., are most often .required during the 
acute stages. Later jaborandi, physostigma, nux, or strych- 
nine should be employed. 



CHAPTER XXXIV. 

THE PERCEPTIVE APPARATUS IN 
ACUTE INFECTIOUS DISEASES. 

Either during or. as a sequelae of diphtheria, influenza, 
measles, mumps, scarlet fever, typhus or typhoid fever, 
variola, etc., the ear is often affected. Often the tympanum 
is first implicated, the labyrinth being secondarily involved, 
but in many cases, especially in scarlatina, the labyrinth is 
primarily affected by the specific poison, and the tympanum 
remains normal. 

Pathology. — The inflammatory action induced may 
cause disintegration of a considerable portion of the audi- 
tory nerve terminals, or may simply result in an effusion 
into the labyrinthine space, increasing the tension of the 
.structures. 

Symptoms. — The variation of audition is considerable, 
and the tinnitus not very annoying. Conversational tones 
are less readily understood than usual, and loud tones, when 
(uttered close to the ear, may be distinctly understood. 

Diagnosis. — Must be made practically by the functional 
examination, as an inspection of the ear seldom reveals the 
condition. In the upper portion of the musical scale, gaps 
are often found. 

Prognosis. — In children, and recent cases in adults, con- 
siderable improvement usually follows proper internal medi- 
cation. 

Treatment. — Jaborandi is probably the most important 
remedy in these cases, the dosage rapidly being increased 
until the physiological action of the drug is obtained. Nux, 

602 



Epidemic Cerebro-Spinai, Meningitis. 603 

ignatia, hydrastis, bryonia, cimicifuga, or physostigma are 
also often indicated. 

Mumps. 

In epidemics of this disease there is often implication of 
the labyrinth. In young children this is a not uncommon 
cause of deafmutism. When seen early, and proper treat- 
ment is instituted, considerable improvement usually fol- 
lows. 

Treatment. — Phytolacca, iris, or potassium iodide are 
usually needed. Jaborandi, bryonia, and cimicifuga less 
frequently. 

Typhus and Typhoid Fever. 

In either of these fevers, the changes produced are prob- 
ably due more to changes in the cerebrum than in the laby- 
rinth. Proper treatment for the exciting cause is usually 
all that is required. 

Epidemic Influenza; Diphtheria. 

In either of these diseases the auditory nerve may be af- 
fected practically the same as the optic nerve, a neuritis 
affecting the nerve trunk, resulting. Sclerotic changes and 
atrophy of the nerve fibers follow in many cases. 

Treatment. — This must be directed to improving the 
general condition. Mental and physical rest are necessary 
for good results. The drugs most frequently required are 
Pulsatilla, nux, and ignatia. 

Epidemic Cerebro-Spinal Meningitis. 

Pathology. — In this condition the inflammatory process 
seems to follow the lymph channels of the vestibular and 
cochlear aqueducts, and affects the structures within the 
bony labyrinth. In the early stages the quantity of the en- 
dolymph and perilymph is increased and there is also a 
change in the character of the fluids. Finally the bony 



604 Nose, Throat and Kar. 

walls are affected by the inflammatory process. Dilatation 
of all the blood vessels occurs, and there is migration of 
the white blood corpuscles into the surrounding tissues, a 
true hypertrophy resulting. As a result of these changes, 
hemorrhages are frequently found. The newly formed tis- 
sue becomes more dense, ^and a bony formation may follow, 
at times even obliterating the semicircular canals or cochlea. 
In some gases necrosis of the tissues occurs, filling the laby- 
rinth with pus. Secondary involvement of the tympanum 
may occur through rupture of the membrane of the oval 
or round windows. 

Symptoms, — Besides the meningeal symptoms there is 
vertigo, sudden loss of audition, and distressing tinnitus. 

Diagnosis. — Inspection of the ear gives negative results, 
but is of value in making the diagnosis by exclusion. Func- 
tional examination shows either marked diminution of hear- 
ing or complete deafness. 

Prognosis. — Unfavorable. If the patient lives there is 
seldom little, if any, improvement in the hearing. 

Treatment. — Internally the use of jaborandi, gelsemium, 
bryonia, or Pulsatilla may slightly improve the hearing, and 
nux or strychnine are sometimes beneficial. 

The Labyrinth in Acute Meningitis. 

Pathology. — In non-epidemic meningitis there may be 
similar secondary labyrinthine changes as occur in the epi- 
demic form. A traumatic meningitis is generally localized, 
and the affection of the labyrinth is usually of one side. 
Besides the changes in the labyrinth, the hearing may be 
affected by direct pressure of inflammatory products upon 
the trunk of the auditory nerve, involvement of the sheath 
of the nerve, or by a circumscribed meningitis over the 
auditory center. The changes which occur in the non-epi- 
demic form are usually not as extensive as in the epidemic 
type. 



Labyrinth in Acute Meningitis. 605 

Symptoms. — These necessarily vary with the location 
and severity of the lesion. The vertigo, tinnitus, and re- 
duction of the audition also depend upon the structures in- 
vaded. 

Diagnosis. — The history of the case is of the utmost 
importance. Inspection often fails to reveal any morbid 
condition, unless the tympanum has been affected. The func- 
tional tests usually show the lower tone limit normal in 
labyrinthine lesions, the upper tone limit much reduced, 
bone conduction slight or none, and conversational tones 
heard relatively less readily than high-pitched tones. Ar- 
tificial aids to hearing do not improve audition. If the 
nerve trunk is subjected to pressure, the notes of the mid- 
dle register are not well heard, while the upper and lower 
tone limits are not much affected. Bone conduction is con- 
siderably diminished, or lost. If the cortical center is af- 
fected, the characteristic tone symptom is the gaps which 
occur. Word deafness, however, is the best evidence of 
cortical involvement. The patient may hear words, but 
can not repeat or define them. In these cases the lesion is 
bilateral, but the defect is most marked upon the side op- 
posite the affected area. Bone conduction is reduced, and 
tone gaps may occur in any portion of the scale. 

Prognosis. — Excepting in meningitis, the result of ab- 
scess and intracranial tumors, the process is not progressive, 
and the hearing often gradually improves. 

Treatment. — Such drugs as will hasten or aid absorp- 
tion are indicated and include jaborandi, bryonia, gelse- 
mium, and potassium iodide. Other remedies which may 
be indicated are pulsatilla, Hydrastis, phytolacca, nux, phy- 
sostigma, and strychnine. 



CHAPTER XXXV. 

INFLUENCE OF DISEASES OF THE 
NERVOUS SYSTEM AND OF GEN- 
ERAL DISEASES UPON THE 
PERCEPTIVE APPARATUS. 

Besides the meningeal inflammation, the hearing power 
may be impaired or destroyed by affections of a degenera- 
tive character in the brain or cord. These may be classed 
as cerebral congestion, apoplexy, cerebral embolism, end- 
arteritis, cerebral tumors, disseminated sclerosis, tabes 
dorsalis. It is not often that a cerebral hemorrhage or em- 
bolism causes much impairment of hearing. 

Word deafness is the most characteristic symptom of a 
cortical lesion. An important subjective symptom is the 
presence of complicated auditory hallucinations, as of 
voices, music, etc. These symptoms may be present in con- 
gestion, hemorrhage, degeneration, sclerosis, or neoplasms. 
If the symptoms are only temporary, the cause is probably 
either congestion or anemia. Associated phenomena must 
be considered in making a diagnosis as well as locating the 
lesion. 

In tabes dorsalis the nerve or the auditory centers may 
be involved in the sclerotic process. 

When the cerebellum is affected, vertigo and nausea 
are predominating symptoms, and the hearing may remain 
practically normal. 

The diagnosis is made more by the general manifesta- 
tions than by the ear symptoms. The treatment must be 
along the line of improvement of the exciting cause. 

606 



Metastasis. 607 

Acute Infectious Diseases with Aural Complications. 

Tympanic inflammation is usually present in the acute 
infectious diseases, if aural complications are present. 
Usually the degree of inflammation is proportionate to the 
severity of the general attack. In measles, varicella, mumps, 
and mild cases of influenza, the tympanum is not often 
seriously affected, the condition being either a tubal ca- 
tarrh or an acute catarrhal otitis media. The more active 
infectious diseases as diphtheria, scarlet fever, typhus fever, 
variola, and in severe cases of rubeola, the inflammation 
often affects the connective tissue, being practically a cellu- 
litis. The condition is the same as when occurring in other 
portions of the body, necrosis resulting and pus forming, 
with later implications of the bony structures. Suppurative 
otitis media is the natural sequence of such an infection. 

The diagnosis and treatment are practically the same as 
already given. 

Nephritis. 

In renal affections the changes found in the ear depend 
upon the general venous obstruction and also upon what is 
called arterio-capillary fibrosis. The tissues are poorly 
supplied with blood as a, result of the changes within the 
walls of the vessels, and a subnormal condition results. Im- 
poverishment of the blood also occurs. Within the tym- 
panum, as a result of these changes, an exosmosis of serum 
follows. This is similar to the pleural effusion found in 
nephritis, and the term otitis media serosa is often used. 
The condition is mechanical and not inflammatory. The 
labyrinth may also be affected, and hemorrhagic lesions in 
the sheath of the auditory nerve may result from this condi- 
tion. 

Metastasis 

A severe suppurative process in any region of the body 
may be the origin of an infective embolus which may be 



608 Nose;, Throat and Ear. 

carried to the tympanum or labyrinth through the circula- 
tory system. The symptoms will depend upon the' occlu- 
sion of the circulation or a secondary infection. Chronic 
suppuration in the accessory nasal cavities may often be a 
factor for the obscure ear symptoms sometimes observed. 
In ulcerative endocarditis any of the anatomical divisions 
of the ear may be affected. In acute pulmonary conditions 
the tympanum is often affected. 

Tuberculosis. 

Usually the first intimation of a tympanic lesion is the 
presence of a discharge in the external auditory canal. In- 
spection will often reveal a complete destruction of the 
drum membrane, and also involvement of the ossicles in 
many cases. If the perforation is small, it is usually round 
and the edges thickened and everted. Frequently in tuber- 
culosis the perforations are multiple. If the ossicles are 
affected, the contiguous bony tissue is soon involved and 
the mastoid is also often implicated in the destructive 
process. 

The diagnosis is usually made through the general con- 
dition and the treatment is that employed for the systemic 
lesion. 

Leukemia. 

Deafness results in this condition as a sequence of the 
passage of minute cells or lymph corpuscles into the chan- 
nels of the labyrinth, diminishing their size and sometimes 
obliterating them entirely. The aural infection is recog- 
nized by the sudden impairment of hearing, which grad- 
ually increases ; vertigo, nausea, and tinnitus are also 
present. 

Diabetes. 

Furunculosis of the external auditory canal is very char- 
acteristic in severe cases. Eczema of the canal and auricle 



Drug Influences. 609 

is frequent in this condition. Disturbances in audition are 
probably the result of hemorrhagic conditions within the 
labyrinth or effusion into the cortical or medullary centers. 

Gout and Rheumatism. 

It is probable that either of these conditions frequently 
affect the ear. A comparatively mild, but persistent eczema 
of the external auditory canal is often found in gouty sub- 
jects. Inflammatory conditions of the tympanum in rheu- 
matic subjects is usually more painful than when uncom- 
plicated. The treatment in these cases is necessarily modi- 
fied by the rheumatic or gouty condition. 

Drug Influences. 

Some drugs exert a markedly deleterious influence 
upon the ear. Quinine is especially pernicious in its effects, 
when administered for any considerable period. Salicin, 
salicylic acid and its salts are also drugs which must be 
cautiously employed in tympanic and labyrinthine conges- 
tions or inflammations. Glonoin, amyl nitrite, nux, and 
strychnine are also to be used with caution in many cases. 
Any drug which increases the flow of blood to the brain 
may have a harmful influence on the ear, especially when 
there is a congestive or inflammatory condition present, and 
the drugs are employed for some time. This applies more 
particularly to the physiological drug action rather than 
the medicinal action. A very common practice is the ad- 
ministration of large doses of quinine for "breaking up a 
cold in the head." This habit should be condemned. To- 
bacco has been credited with impairing the hearing, but the 
probability is its influence is exerted through the effects 
produced upon the general nervous system. 

39 . 



610 Nose, Throat and Ear. 

The Influence of Functional Nervous Conditions upon 
the Hearing. 

The functional nervous conditions most often found are 
neurasthenia and hysteria. It is often difficult to determine 
whether there is a co-existing lesion of the ear or not, but 
in many cases there probably is, and the nervous manifesta- 
tion is simply more prominent in this region through this 
morbid condition. 

Neurasthenia. 

These cases usually present a condition of the nervous 
system in which any extra exertion produces an exagger- 
ated degree of impairment of any organ affected. In the 
ear the term "auditory strain" is often used for the auditory 
manifestations. Following the sleeping hours, the hearing 
may be fairly good, but later the impairment of hearing- is 
often very marked. Sensitiveness regarding the ability to 
understand increases the condition, and often the patient 
becomes a hypochondriac, or in extreme cases, acute melan- 
cholia may result. The patient usually hears better in a 
quiet place. An annoying tinnitus is always present, and 
is increased when tired. There may be a sense of formica- 
tion or of occlusion of the external auditory canal. The 
hearing often varies during an examination. 

Diagnosis. — Either inspection or a functional examina- 
tion often reveals but little, excepting as the general condi- 
tion is considered. All tests may be negative, unless con- 
tinued for some time, when the variations of, or diminished 
acuity of hearing may be observed. 

Prognosis. — Unless there are marked changes, the prog- 
nosis will depend upon the ability to improve the general 
nervous condition. 

Treatment. — Care in the selection of drugs is necessary. 
Pulsatilla, ignatia in small doses, rhus tox., gelsemium, hy- 
drobromic acid dil., the bromides, and occasionally physos- 
tigma are the drugs most frequently required. 



Reflex Aural Disturbances. 6ii 

Freedom from any over-exertion is also an important 
aid in these cases, and often a complete change of scene and 
associations will be beneficial. Nux, strychnine, or ignatia 
in large doses, as well as quinine or any drug which in- 
creases nervous excitability should be avoided. 

Hysteria. 

In this condition, which is often present in neurasthenia, 
the symptoms are practically the same. 

Symptoms. — As a rule the deafness appears suddenly, 
and may be considerable or absolute. It often follows a 
mental shock, and usually is permanent. An abrupt res- 
toration of hearing may occur without any apparent cause. 
The condition may be unilateral, and suddenly shift to the 
opposite side, or both ears may be affected at the same time. 
Pain in the region of the ear or of the mastoid is not in- 
frequent. Vertigo and tinnitus are usually absent. 

Diagnosis. — This must be made by the general condition 
of the patient as a rule, as all tests are usually negative as 
regards any characteristic condition. 

Prognosis. — This will depend upon the ability to relieve 
the hysterical condition. 

Treatment. — The remedies indicated in hysteria are to 
be employed. 

Reflex Aural Disturbances. 

Morbid conditions in any region of the body may induce 
either functional or structural changes in the ears. The 
most logical explanation for the changes is that circulatory 
disturbances are responsible for the disturbance. In the 
conducting portion of the ear, visual changes may be noted, 
but in the perceptive region a functional examination only 
will show an abnormal deviation. The recognition of the 
case is often difficult, and the outcome will depend upon 
the ability to relieve the exciting cause. 



CHAPTER XXXVI. 
DEAF-MUTISM. 

Either congenital deafness or the loss of hearing in 
early childhood is a cause of mutism. In many' cases it is 
impossible to decide the exact condition. 

Etiology. — Heredity is often a factor, and degeneration 
or a hereditary specific condition may be a cause. In- 
juries to -the head during parturition, or attacks of acute 
infectious diseases during infancy, may result in deaf- 
mutism. Acute or chronic inflammatory intracranial af- 
fections, or adenoids in early childhood may be factors. 

Pathology. — A congenital defect in some portion of the 
auditory mechanism, or an acquired lesion may account for 
this condition. The changes are varied, and any part of 
the conducting or perceptive apparatus may be affected. 

Symptoms. — Lack of attention to conversation or loud 
noises often first attracts attention to an aural defect. 

Diagnosis. — The variation in the age of children in com- 
mencing to articulate, and also in infancy in noticing 
sounds, varies, and it is often difficult to determine whether 
it is a case of deafness or of delayed perception of sound. 
A history of hereditary deafness, of intracranial affections, 
or of any abnormality of the ear should be considered in 
making a diagnosis. 

Prognosis. — Always guarded, especially in cases under 
the age of eighteen months. 

Treatment.- — This must be governed entirely by the 
cause. In some cases operative measures are required, as 
where there is much impairment of nasal respiration, either 

612 



Artificial, Aids to Hearing. 613 

through nasal malformations or adenoid vegetations. 
Medicinal measures are of no value in these cases. When 
free nasal respiration is present, therapeutic measures may 
benefit the patient in some instances. The use of some ap- 
pliance for stimulating the auditory tract is also of occa- 
sional value, but a careful study of each case must be made. 

Artificial Aids to Hearing. 

Various appliances have been brought to the notice of 
a confiding public for the improvement of the hearing, but 
none have been universally successful. Ear drums, con- 
versation tubes and ear trumpets of different designs, are 
on the market. The only way to determine positively 
whether any of these instruments will be beneficial is by a 
trial. Ear drums are of no benefit unless the membrana 
tympani has been destroyed, and in many cases a thin layer 
of cotton will be equally as effective as the expensive ear 
drum. The instruments which are • beneficial when the 
membrana tympani is not destroyed, can be tried at any 
instrument makers, and such as appear to give the best re- 
sults may be employed. 



CHAPTER XXXVII. 

MATERIA MEDICA AND THERA- 
PEUTICS. 

The drugs mentioned under this heading are those which 
have been found most efficacious. .The variation in dosage 
depends upon the condition, whether destructive 'or not, and 
also whether acute or chronic. In chronic cases the doses 
are smaller than in acute types, and the dose is always for 
adults unless otherwise stated.* 

Acidum Arsenosum. — In the chronic dry scaly form of 
eczema of the auricle or external auditory canal. Gr. i-ioo. 

Acidum Boricum, Boric Acid. — This is used either alone 
or in combination in suppurative otitis media, dusting the 
powder lightly with the DeVilbiss powder blower. In an 
acute suppurative otitis media, the plain boric acid is all 
that is usually required. In chronic cases I generally em- 
ploy combinations, the names employed for these being 
more for the sake of convenience than anything else. 

Carbolized Boric Acid. — Boric acid to which is added 
live per cent carbolic acid and thoroughly triturated. Indi- 
cations: Hypersensitive mucous surface; moderately pro- 
fuse discharge, fetid, not purulent. 

Calendulated Boric Acid. — JJ Sp. med. calendula, boric 
acid aa q. s. Triturate until a dry powder results. Indica- 
tions: Moderately profuse, thin, acrid pus. 

Ergotized Boric Acid. — R Squibb's ergot §ss, boric acid 



*Many drugs employed are not mentioned in this list as the indications 
for their use is the same as is mentioned in all Eclectic text-books, and so 
are not repeated here. 

614 



Materia Mkdica and Therapeutics. 615 

§j. Triturate the same as the calendulated product. Indi- 
cations: Membranes turgid and reddened; slight discharge. 

B orated Iodoform. — Iodoform 3j boric acid 3ij. Indica- 
tions: Pallid mucous membrane; discharge scanty. 

Salicylated Boric Acid. — Lloyd's Salicylic acid 3j, boric 
acid oyj. Indications: Polypoid granulations, or a soggy 
condition of the mucous tissue. 

Thuja Boric Acid. — Sp. med. thuja 3j, boric acid 5ij-iv. 
Triturate, Indications: Papillomatous granulations of the 
mucous membrane. 

These combinations are most frequently employed. It 
is necessary in their preparation that no glycerin is present 
in the liquid drugs used, and considerable time is necessary 
to properly triturate the mixture, as the finished article 
should be free from any lumps. 

Acid Hydrobromicum Dilutum. Diluted Hydrobromic 
Acid. — In tinnitus resulting from the use of quinine, or 
the tinnitus of nervous persons. Dose, gtt. ss-j. 

Acidum Phosphoricum Dilutum. Diluted Phosphoric 
Acid. — Atony of the nervous system and functional deaf- 
ness. Dose, gtt. j. 

Acidum Salicylicum. Salicylic Acid. — Lloyd's prepara- 
tion is the one employed. Internally in some of the rheu- 
matic or gouty conditions. The indications are a full, moist, 
purplish, or leaden-colored tongue. Locally the use with 
boric acid has been given. 

Salicylic Acid Ointment. — Lloyd's salicylic acid gr. xx, 
white vaselin gj. Indications: Dry scaly eczema of the ex- 
ternal auditory canal. Boggy, edematous state of the tur- 
binal tissues. In the latter condition the ointment should 
be applied on a pledget of cotton that fills the space between 
the turbinate and septum, and should be left in position an 
hour. Do not repeat the application to the same side oftener 
than every fourth day. 



616 Nosk, Throat and Ear. 

Salicylic Acid Wash. — 1> Lloyd's salicylic acid 3ss, 
sodium borate 3jss, Lloyd's hydrastis gj, aqua q. s. giv. 
Use in atomizer. Indications: As a cleansing and depleting 
solution. Also appears to possess a stimulating action on 
the mucous glands. If there is a profuse, thin watery, non- 
excoriating discharge, distilled hamamelis should be sub- 
stituted for the water. 

Aconitum. Aconite. — In acute fibrile conditions follow- 
ing the usual indications. In tonsillitis the dosage and fre- 
quency should be increased until the tingling sensation of 
the tongue is marked, then repeated often enough to keep 
a slight sensation of tingling. 

Alkaline Wash. — 1> Sodium bicarbonate. Sodium bo- 
rate. Sodium chloride aa gr. xxxij, aqua giv. This is used 
for removing excessive secretion or for softening crust 
formation. 

Ammonii Bromidum. Ammonium Bromide. — In nerv- 
ous deafness, and also tinnitus from the use of quinine. 
Dose, gr. ij-v. 

Apis. — Edema of the tissues and scanty urine. Dose, 
gtt. i-io — 1-6. 

Apocynum. — Excessive edema of the tissues and scanty 
urine. It may be combined with apis. Dose, gtt. 1-3 — j. 

Aqua Hamamelidis. Distilled Hamamelis. — Indications: 
Internal. — Profuse thin, watery, non-excoriating discharge 
from the nose. In passive epistaxis it is a valuable remedy. 
In pharyngeal conditions, where a varicosed venous ap- 
pearance is present, or where there is a venous stasis with a 
hemorrhoidal condition, the drug is indicated. Dose, gtt. 
ij-v. Locally, as already stated under salicylic acid wash. 

Arseni Iodidum. Arsenic Iodide. Iodide of Arsenic. — 
In scrofulous and anemic cases, also when there is the com- 
bination of scrofula and hereditary syphilis. Dose, gr. 1-200 
—1-50. 



Materia Medica and Therapeutics. 617 

Asclcpias. — When the pulse is strong and vibratile; 
skin moist ; inflammation of serous tissues. Dose, gtt. 
1-3— ss. 

Auri et Sodii Chloridum. Gold and Sodium Chloride. — 
In syphilitic cases, either the later stages of acquired, or in 
the hereditary form, especially when there is necrosis of 
the bony tissue. Dose, gr. 1-100 in solution. 

Baptisia. — In faucial or pharyngeal inflammation when 
the mucous membrane presents a dusky, leaden-colored hue, 
and there is a disposition to septic ulceration. The breath 
is offensive. Dose, gtt. ss — 2-3. ' 

Bryonia. — Pain increased by motion. Pain extending 
from the throat to the ear on swallowing. Dose, gtt. 1-3 — ss. 

Calx Sulphurata. Calcium Sulphide. — In suppurative 
conditions of the sinuses, tympanum and mastoid. Also in 
purulent secretion from the nasal cavities or naso-pharynx. 
Dose, gr. 1-100 — 1-10, increasing to saturation in acute 
tympanic and mastoid suppurative types. 

Cannabis Indica. — In migraine, some forms of nervous 
headache, and facial neuralgia in women during the men- 
strual period or at the menopause. In cerebral anemia and 
a subnormal mental state it is useful. Dose, gtt. 1-6 — j. 

Carbo Ligni. Carbo Vegetabilis. — In epistaxis, espe- 
cially if passive in character. Preparation, iX trituration. 
Dose, gr. v — x. 

Chloroformum. Chloroform. — In acute catarrhal otitis 
media, chloroform vapor will relieve the pain quicker and 
oftener than any other means. Care must be exercised that 
none of the liquid enters the canal, as it will vesicate and 
increase the pain. Preferably used in a De Vilbiss powder 
blower. 

Cimicifuga. Macrotys. — Where the tissues have a 
bruised feeling. In rheumatic pharyngitis with the bruised 
sensation. Dose, gtt. ss — j. 



618 Nose, Throat and Ear. 

Coca. — In extreme hoarseness where it is imperative the 
voice should be used. Especially in those cases where there 
is an apparent relaxation of the vocal cords. Dose, gtt. 
iij — x. 

Collinsonia. — In laryngitis and also in pharyngitis where 
the tendency is to irritation of the larynx. The aromatic 
collinsonia, which is made from the fresh herb, is the prepa- 
ration employed. Dose, gtt. iij — xv. 

Cuprum. — Anemic and chlorotic conditions, with the 
mucous tissues pallid. Dose, gtt. 1-5. 

Echinacea. Bchafolta. — Mucous membranes dusky, ul- 
cerated, and a general debility. The breath is fetid. There 
is a condition of sepsis. Dose, gtt. j — v. 

Br got a. Br got. — In epistaxis, active in character. Dose, 
gtt. v — xv. 

Gelsemmm. — In acute catarrhal otitis media, and in 
sinus affections, gelsemium will afford relief by increasing 
the fluidity of the secretion. In neuralgia of the supraor- 
bital nerve, this drug in combination with bryonia will 
usually afford prompt relief. Dose, gtt. ss — ij. 

Glycerinum. Glycerin. — A large pledget of cotton sat- 
urated with glycerin and allowed to remain in position for 
half an hour will deplete edematous nasal tissues, and often 
relieve the pressure in the accessory sinuses by relieving the 
swelling around their openings, in a short time. It is sel- 
dom more than two applications are necessary. 

Grindeiia. — Asthmatic conditions and a harsh, dry 
cough. Dose, gtt. x — xxx. 

Hydrastis. — In catarrhal conditions where the secretion 
is moderately profuse, moderately thick, and not purulent. 
In atony of the mucous tissues it is also indicated. Dose, 
gtt. j— ij. 

Ignatia. — Especially indicated in nervous females who 
suffer from uterine disturbances, but are not apprehensive. 
The hearing is often impaired and tinnitus is frequently 



Materia Medica and Therapeutics. 619 

present. There is general atony of all tissues. Dose, gtt. 
1-6— 1-5. 

Ipecacuanha. Ipecac. — Especially valuable in croupous 
conditions, but should not be carried to the point of emesis. 
Dose, gtt. 1-6 — ss. 

Iris. — In enlargement of the lymphatics with a sluggish 
lymphatic circulation this drug is indicated. The glands 
are soft. Dose, gtt. ss — v. 

Liquor Arseni et Hydrargyri Iodidi. Donovan's Solu- 
tion. — In secondary syphilis with an elongated, contracted, 
pointed tongue. Papillae prominent and reddened. Dose, 
gtt. ss— j. 

Liquor Potassii Arsenitis. Fowler's Solution. — In 
chronic eczema of the auricle and canal. The dry scaly 
form especially. In excessive, thin, watery, excoriating dis- 
charge fromthe mucous membranes. Dose, gtt. ss — j. 

Lobelia. — In laryngeal spasms the drug should be given 
in nauseant doses, but not to the point of emesis. Dose, 
gtt. ss — iij. 

Nitx Vomica. — In catarrhal conditions where the mu- 
cous tissues have a relaxed appearance. 

Contraindicated in neurotic persons, or where there is 
an irritable condition of the central nervous system. Dose, 
gtt. 1-5— 1-3. 

Physostigma. — In inflammatory conditions of the me- 
ninges, and congestive states of the brain or of the labyrinth, 
the drug is often indicated. Mental dullness in cerebro- 
spinal meningitis is an indication. Dose, gtt. 1-10 — 1-5. 

Phytolacca. — Indicated in enlargement of the lymphatics 
especially when they are hard. Also when the mucous fol- 
licles are distended with secretion. Its action on the 
mucous glands is such that the tendency to the formation 
of a false membrane is lessened. In tonsillar affections, es- 
pecially acute, this drug in combination with aconite is 
nearly a specific. In chronic enlargement of the tonsils, 



620 Nose, Throat and Ear. 

unless hyperplastic in character, phytolacca continued for 
some time will often diminish their size. In chronic rhi- 
nitis, and often in atrophic rhinitis, this remedy through its 
action on the mucous glands will afford relief. The same 
is true of follicular and atrophic pharyngitis. Dose, gtt. 
j — v. This varies according to the amount of inflammation 
present. In acute cases the maximum dose is often re- 
quired, and in chronic conditions the minimum. dose. 

Pilocarpus. Jaborandi. — Especially indicated in atrophic 
conditions of the mucous tissues of the nose, pharynx, and 
larynx. The surfaces present a dry, parched appearance. 
In -labyrinthine diseases, particularly where there is effu- 
sion, the drug relieves by promoting absorption. Dose, gtt. 
iij — viij. 

Piscidia. Jamaica Dogwood. — Frequently required in 
neuralgic affections of the trifacial nerve, especially when 
opium or its derivatives are contraindicated. Dose, fl. ext. 
gtt. v — xv. 

Potassii Bichromas. Potassium Bichromate. — Indicated 
when there is a tough, tenacious, stringy mucus. Also with 
crust or scab formation in the nose, and when the crusts are 
dislodged they are streaked with blood, and a slight hemor- 
rhage follows. Also in superficial ulceration of the septum. 
Locally. A two per cent solution. Internally, gr. i-ioo, 
preferably in tablet form. 

Potassii Iodidum. Potassium Iodide. — In small doses in 
atrophic states of the mucous membrane and labyrinthine 
diseases. Earge doses whenever a destructive process ap- 
pears, due to specific disease. Dose, gr. j — xxx. Always 
give plenty of water with each dose. 

Pulsatilla. — Whenever an apprehensive condition is 
present, this drug affords relief. In acute catarrhal otitis 
media, this drug combined with gelsemium usually gives 
prompt relief. Dose, gtt. j. 



Materia Medica and Therapeutics. 621 

Quinina. Quinine. — Contraindicated in practically all 
ear affections. 

Rhus Toxicodendron. — The indications for this drug 
are : pain diminished or relieved by motion ; elevated pa- 
pillae at the tip of the tongue, the tongue being pointed and 
the edges reddened. Dose, gtt. 1-10 — 1-6. 

Sticta. — When there is a feeling of fullness at the root 
of the nose, and with a disposition to blow the nose without 
any secretion being dislodged. Dose, gtt. 1-6 — 1-5. 

Strophantus. — In cardiac insufficiency or muscular de- 
bility. Dose, gtt. ss — iij. 

Strychnine? Sulphas. Strychnine Sulphate. — The indi- 
cations and contraindications are practically the same as for 
nux. Dose, gr. 1-100 — 1-30. 

Syrupus Ferri Iodidi. Syrup of Iodide of Iron. — In 
some cases of specific disease this is better tolerated than 
any other iodide. Dose, gtt. x — xx. 

Thuja. — In syphilitic erosions and ulcerations in the 
nose, mouth, or pharynx, the local application of thuja will 
usually be followed by rapid healing. As a mouth wash in 
these cases, the use of thuja, Lloyd's hydrastis aa 3ij, glyc- 
erin, 3jv, a teaspoonful of this added to enough water to 
rinse the mouth thoroughly, will also aid in the recovery 
from specific buccal lesions. 

Veratrum Viride. — In sthenic conditions and trauma- 
tisms, with the pulse rapid, full, and bounding. Dose, gtt. 



BIBLIOGRAPHY. 



Accessory Sinuses of the Nose Turner. 

American Dispensatory Felter-Lloyd. 

American Text Book, Eye, Ear, Nose, and Throat. 

Anatomy Gray. 

Anatomy Holder). 

Anatomy and Diseases of Eye and Ear Roosa and Davis. 

Anomalies and Curiosities of Medicine Gould and Pyle. 

Atlas of Diseases of the Larynx Griinwald and Grayson. 

Atlas of Diseases of the Mouth, Pharynx and Nose 

Griinwald and Newcomb. 

Atlas of Nervous System Jakob and Fisher. 

Atlas of Otology Bruhl and Politzer. 

Comparative Anatomy and Physiology Bell. 

Cyclopedia of Medicine Sajous. 

Deafness, etc Woakes. 

Diseases of the Brain and Cord Macewan. 

Diseases of Children Mundy. 

Diseases of the Ear Dench. 

Diseases of the Ear Politzer. 

Diseases of the Nervous System Hammond. 

Diseases of the Nose and Throat Bosworth. 

Diseases of the Nose and Throat Coakley. 

Diseases of the Nose, Throat, and Ear Friedrich and Curtis. 

Diseases of the Nose, Throat, and Ear Gradle. 

Diseases of the Nose and Throat Kyle. 

Diseases of the Nose and Throat Knight. 

Diseases of the Nose and Throat Price-Brown. 

Diseases of the Nose and Throat Sajous. 

Diseases of the Nose and Throat Shurly. 

Diseases of the Upper Respiratory Tract Williams. 

Dynamical Therapeutics Webster. 

Electricity in Diseases of the Ear, Nose, and Throat. . .Scheppegrcll. 

Essential Diseases of Nose and Throat Gleason 

Handy Guide in Materia Medica ...... Niederkorn. 

623 



624 Bibliography. 

Manual of Botany .Gray. 

Manual of Otology Bacon. 

Mastoid Operation Whiting. 

Materia Medica and Therapeutics Ellingwood. 

Materia Medica Fyfe. 

Materia Medica Locke-Felter. 

Materia Medica and Therapeutics Scudder. 

Materia Medica and Therapeutics , Shoemaker. 

Materia Medica Goss. 

Medicated Inhalations Scudder. 

Nervous and Mental Diseases Church and Peterson. 

Newer Remedies* Coblentz. 

Normal Histology Piersol. 

Nose, Throat, and Ear Bishop. 

Nose and Throat Ivins. 

Nursing in Eye, Ear, Nose, and Throat Davis and Douglas. 

Organic Materia Medica Maisch 

Pathogenic Bacteria McFarland. 

Fathology and Morbid Anatomy Green. 

Pathological Anatomy Jeancon. 

Physiology . Foster. 

Physiology Kirke. 

Post-nasal Catarrh Woakes. 

Practice of Medicine Anders. 

Practice of Medicine Loomis. 

Practice of Medicine Osier. 

Practice of Medicine Scudder. 

Practice of Medicine Thomas. 

Practice of Medicine Watkins. 

Practice of Medicine ! , Webster. 

Principles of Otology Buck. 

Specific Diagnosis Scudder. 

Specific Medication Scudder. 

Studies in Psychology of Sex Ellis.. 

Surgical Anatomy and Operative Surgery of the Middle Ear. .Broca. 

Surgical Anatomy of the Head and Neck Deaver. 

Surgical Diseases of the Face, Mouth, and Jaws • Grant. 

System of Diseases of the Ear, Nose, and Throat Burnett. 

System of Practical Therapeutics Hare. 

Text-book of Diseases of the Eye, Ear, Nose, and Throat 

Ballinger and Whippern. 

The Ear ■ Burnett. 

Treatise on Diseases of the Ear. . Roosa. 



INDEX 



Abscess, acute, of septum, 294 
acute of uvula, 340 
chronic of septum, 295 
chronic of tonsil, 370 
of auricle, 522 
cerebellar, 592 
cerebral, 591 
retropharyngeal, 418 
tonsillar or peritonsillar, 360 
Accessory cavities, 13 
Accessory sinus mucous mem- 
brane, 17 
sinuses, 13 

sinuses, diseases of, 298 
Acidum boricum, 614 
calendulated, 614 
carbolized, 614 
ergotized, 614 
salicylated, 153, 615 
and iodoform or borated 

iodoform, 615 
and thuja, 615 
carbolic, 204 
chromic, 200 

hydrobromicum dilutum, 615 
lactic, 200 
phosphoricum dilutum, 227, 

6l 5 
salicylicum, 200, 615 
salicylic, ointment, 146, 615 

wash, 146, 148, 616 
tannic, 236 
Acne of nose, 230 
Aconite, 141, 616 
Actinomycosis of maxillary 
sinus, 307 
nasal, 210 
of pharynx, 416 
Acute bulbar paralysis, 343 
catarrh of the larynx, 434 
catarrh of the nasopharynx, 
328 



Acute catarrhal angina, 354 
laryngitis, 434 
otitis media, 553 
pharyngitis, 380 
tonsillitis, 354 
cellulitis of the larynx, 448 
circumscribed external otitis, 

528 
coryza, 135 

diffuse external otitis, 532 
edematous rhinitis, 156 
epiglottitis, 445 
idiopathic rhinitis, 135 
infectious diseases, aural com- 
plications in, 607 
involvement of inner ear 
in, 602 
of perceptive mechanism, 
in, 602 
inflammation of labyrinth, 
secondary to acute pu- 
rulent otitis media, 600 
laryngitis in children, 439 

in constitutional diseases, 436 
nasal blenorrhea, 135 

catarrh, 135 
nasopharyngitis, 328 
post-nasal catarrh, 328 
purulent discharge from mid- 
dle ear, 557 
purulent otitis media, 557 
retronasal catarrh, 328 
rheumatic pharyngitis, 405 
rhinitis, 135 

in children, 142 
rhinopharyngitis, 328 
rhinorrhea, 135 
salpingitis, 549 
tubo-tympanitis, 552 
uvulitis, 339 
Adenocarcinoma, 276 
Adenoid vegetations, 346 



625 



626 



Index. 



Adenoiditis, chronic, 330 

Adenoids, 346 

Adenoma of anterior nares, 247 

of fauces, 247 

of larynx, 248 

of nasopharynx, 247 
Aids to hearing, artificial, 613 
Alse, nasal, collapse of, 289 
Alkaline solution or wash, 14S, 

616 
American catarrh, 330 , 
Ammonii bromidum, 616 
Anatomy of anterior nasal cavi- 
ties, 10 

of ear, 45 

of ethmoidal cells, 15 

of fauces and oropharynx, 2^ 

of faucial tonsils, 25 

of frontal sinus, 15 

of inferior turbinate, 13 

of larynx, 29 

of lingual tonsil, 345 

of Luschka's tonsils, 28 

of mastoid, 574 

of mucous membrane of ac- 
cessory sinuses, 17 

of mucous membrane of nasal 
cavities, 17 

of nasal tonsil, 345 

of nose, 9 

of pharyngeal tonsil, 28 

of pharynx, 27 

of postnasal space, 10, 21 

of septum, 10 

of sinuses, 15 

of antrum of Highmore, 
15, .16 

of ethmoidal sinus, 15 

of frontal sinus, 15 

of maxillary sinus, 15, 16 

of sphenoidal sinuses, 13 

of tonsils, 25 
Anemia of labyrinth, 593 

of larynx, 469 

of pharynx, 425 
Anemic rhinitis, 145 
Anesthesia of larynx, 487 

of pharynx, 426 
Angina, acute catarrhal, 354 

benign croupous, 420 

diphtheritica, 

Ludovici, 392 

Ludwig's, 392 



Angioma of nasal cavity, 248 
of auricle, 525 
of fauces, 249 
of larynx, 250 
of pharynx and uvula, 250 
of tonsil, 250 
Angioneurotic edema of larynx. 

468 
Anomalies of upper respiratory 

tract, 129 
Anosmia, 220, 221 
Anterior nasal cavities, angioma 
of, 248 
ulcers of, 213 
Anterior nares, adenoma of, 247 
Antihelix, anomalies or malfor- 
mations of, 512 
Antitragus, anomalies or mal- 
formations of, 512 
Antrum of Highmore, 15, 16 
Aphonia, hysterical, 489 
Aphthous throat, 420 
Apis, 157, 616 « 

Apocynum, 157, 616 
Apoplectiform, bulbar paralysis 

of soft palate, 344 
Aprosexia, 229, 230 
Aqua hamamelidis, 616 
Arsenic iodide, 148, 176, 177, 

227, 616 
Arteries of the ear, 61 
Artificial aids to hearing, 613 
Asclepias, 617 
Asthma, reflex nasal, 220, 228 

rachiticum, 440 
Atheroma of the auricle, 525 
Atrophic catarrh, 170 
endorhinitis, 170 
laryngitis, 466 
nasal catarrh, 170 
nasopharyngitis, ^33 
pharyngitis, 402 
rhinitis, 170 
Atrophy due to local manifesta- 
tion of systemic lesion, 
177 
from a pre-existing local 

lesion, i/i 
of tonsil, 370 
Auditory nerve, 75 
Aural complications in acute in- 
fectious diseases, 607 
in diabetes, 608 



Index. 



627 



Aural disturbances, reflex, 229, 
611 

through drug influences, 609 
involvement in gout and rheu- 
matism, 609 

in hysteria, 611 

in leukemia, 608 

in metastasis, 607 

in nephritis, 607 ' 

in neurasthenia, 610 

in syphilis, 597 

in tuberculosis, 608 
reflexes, 611 
Auricle, 45, 46, 512 
abscess of, 522 
angioma of, 525 
atheroma of, 525 
benign tumors of, 525 
cutaneous diseases of, 515 
cystoma of, 526 
diseases of, 515 
eczema of, 517 
epithelioma of, 527 
erysipelas of, 522 
fibroma of, 526 
gangrene of, 523 
hematoma of, 522 
herpes of, 519 

inflammatory affections of, 515 
injuries of, 515 
intertrigo of, 517 
lipoma of, 527 
lupus of, 521 

malignant tumors of, 527 
ossification of, 523 
papilloma of, 527 
pemphigus of, 519 
perichondritis of, 521 
sarcoma of, 527 
syphilis of, 520 
wounds of, 515 
Autumnal catarrh, . 224 

Bacilli found in normal nose, 

126 
Bacillus leprae, 207 

mallei, 204 
Baptesia, 384, 617 
Belladonna, 141 
Benign croupous angina, 420 
Blenorrhea, acute nasal, 135 

chronic, 158 



Blood-cyst of septum, 296 
Boils in external auditory canal, 
528 

in nose, 211 
Bony canal, 47 

labyrinth, 69 
Bryonia, 141, 617 
Buccal tonsil, 371 

Cactus, 237 

Calcium sulphide, 212, 617 
Calx sulphurata, 212, 617 
Canal bony, 47 

cartilaginous, 46 

external auditory, 528 
Cannabis indica, 617 
Capsule labyrinthine, rarefying 
osteitis of in otosclero- 
sis, 571 
Carbo veig., 148, 237, 617 
Carcinoma of nasal cavities, 264 

of nasopharynx, 265 

of pharynx, 266, 268 

of soft palate, 266 

of tonsil, 268 
Cartilages of nose, depression 

of, 296 
Cartilaginous meatus, 46 
Caseous rhinitis, 149 

tonsillitis, 369 
Catarrh, acute of larynx, 434 

acute nasal, 135 

acute nasopharyngeal, 328 

acute postnasal, 328 

acute retronasal, 328 

American, 330 

atrophic, 170 

autumnal, 224 

chronic, of larynx, 461 

chronic, nasal, 158 

dry, 170 

Eustachian, 549 

hypertrophic nasal, 164 

of pharyngeal bursa, 330 

pollen, 224 

postnasal, chronic, 330 

purulent nasal, 179 

retronasal, chronic, 330 

rose, 224 

specific, 183 

summer, 224 

tubo-tympanic, 552 



628 



Index. 



Catarrhal croup, 443 
Catarrhal inflanimation, 120 
acute, 120 
chronic, 121 
of ethmoid cells, 311 
of^frontal sinus, 320 
of'maxillary sinus acute, 298 
of maxillary sinus chronic, 306 
of middle ear, acute, 553 
of sphenoidal sinus, 316 
laryngitis. 443 

acute, 434 
pharyngitis, acute 380 
rhinitis, 135 
Catarrhus sestivus, 224 
Catarrhus longus, 158 
Catheterization of Eustachian 

tube, 102 
Cavity, tympanic, 49 
Cellulitis of larynx, acute, 448 

of neck, 392 
Cerebellar abscess, 592 
Cerebral abscess, 591 

croup, 440 
Cerumen, impacted, 539 
Child crowing, 440 
Chloretone, inhalant, 200 
Chloroform, 242, 556, 617 
Cholesteatomatous rhinitis, 149 
Chondritis of larynx, 454 
Chondroma of nasal cavities, 250 
of larynx, 251 
of nasopharynx, 251 
Chorditis tuberosa, 470 
Chorea of larynx, 490 

neurosis, reflex nasal, 229 
Chronic abscess of septum, 295 
of tonsil, 370 
adenoiditis, 330 
atrophic rhinitis, 170 
blenorrhea, 158 
bulbar paralysis, 343 
catarrh of the larynx, 461 
of the nasopharynx, 330 
catarrhal otitis media, 567 
circumscribed external otitis, 

532 
coryza, 158 

diffuse external otitis, 534 
edema of larynx, 450, 468 
edematous rhinitis, 182 
fetid rhinitis, 170 



Chronic hyperplastic otitis 
media, 571 
hypertrophic otitis media, 568 

rhinitis, 164 
infectious (specific) inflam- 
mations, 124 
nasal catarrh, 158 
nasopharyngitis, 330 
non-suppurative catarrh of 
middle ear, 567 
otitis media, 568 
postnasal catarrh, 330 
purulent otitis media. 561 
retronasal catarrh, 330 
rheumatic pharyngitis, 407 
rhinitis, 158 
rhinopharyngitis, 330 
rhinorrhea, 158 
specific inflammatory proc- 
esses, 124 
suppurative inflammation of 

middle ear, 564 
uvulitis, 340 
Cimicifuga, 141, 617. 
Circumscribed external otitis, 

528 
Cirrhotic rhinitis, 170 
Clergyman's sore throat, 393, 

397 
Clinical phenomena of inflam- 
mation, 118 
Clonic spasm of pharynx, 427 
Coca, 618 
Cocaine, 141 
Cochlea, 71 
Cod liver oil, 180 
Colchicum, 295 

Cold, or cold in the head, 135 
Collapse of nasal alse, 289 
Collinsonia, 618 
Common membranous sore 

throat, 420 
Common sporadic catarrh, 135 
Congenital syphilis of nose, 193 
Congestion, tubal, 549 

tubo-tympanic, 552 
Congestive headache, 220, 229 
Consumption of the larynx, 478 
of the pharynx, 408 
of the throat, 478 
Corrosive mercuric chloride, 
191 



Index. 



629 



Corti, organ of, 37 

rods of, 73 
Coryza, acute, 135 

caseosa, 149 

chronic, 158 

fetid, 170 

idiosyncratic (vasomotoria 
periodica), 224 

vasomotoria,periodica, 224 
Cough, 228 
Crataegus, 146 , 
Croup, catarrhal, 443 

cerebral, 440 

diphtheritic, 450 

false, 439, 440. 443 

fibrinous, 450 

idiopathic membranous, 450 

membranous, 451 

mucous, 443 

pseudomembranous, 451 

spasmodic, 439, 440, 443 

spurious, 434, 443 

true, 451 
Croupous external otitis, 538 

laryngitis, 450 

pharyngitis, 384 
Cryptic tonsillitis, 355 
Cuprum, 177, 618 
Cutaneous diseases of the auri- 

. cle > 515. . 
Cyanotic laryngitis, 468 

rhinitis, 182 
Cynanche trachealis, 450 
Cystoma of auricle, 526 
Cysts, 276 

classification of, 276 

cystoma, 277 

dermoid, 277 

simple or retention, 276 

Deaf-mutism, 612 

Deflections of septum, 281 

Deformities of septum, 281 

Dentigenous cyst, 310 

Depression of nasal cartilages. 
296 

Dermoid cysts, 277 

Diabetes mellitus, aural compli- 
cations in, 608 
acute rhinitis in, 144 

Diabetic nasal ulcers, 213, 216 

Diffuse external otitis, 532 



Diphtheria, acute rhinitis in, 144 

involvement of internal ear 
in, 603 
Diphtheritic croup, 450 

external otitis, 538 

rhinitis, 154 
Discrete tonsil, 346 
Diseases of the accessory sin- 
uses, 298 

of the perceptive apparatus, 
593 
Distilled hamamelis, 616 
Diverticula or dilatation of 

pharynx, 379 
Dome of pharynx, 10 
Donovan's solution, 191, 619 
Drugs affecting the ear, 609 
Dry catarrh, 170 

laryngitis, 466 

nasal catarrh, 170 

pharyngitis, 402 
Dysodia, 170 
Dysphonia clericorum, 397 

spastica, 491 

Ear, anatomy of, 45 

blood supply of, 61 
Ear affections, neuroses, reflex 
nasal, 229 
histology of, 64 
internal, 45, 69 

involvement of in acute infec- 
tious diseases, 607 
in diabetes, 608 
in gout and rheumatism, 609 
in leukemia, 608 
in nephritis, 607 
in syphilis, 597 
in tuberculosis, 608 
lymphatics of, 63 
malformations of, 512 
muscles of, 60 
nerves of, 63 

physical examination of, 96 
Earache, 553 
Echafolta. 618 
Echinacea, 384, 618 
Ecthyma of pharynx, 420 
Eczema of auricle, 517 
Edema, chronic of larynx, 450, 
468 
glottidis, 448 



630 



Index. 



Edema, chronic of glottis, 448 

of larynx, 448, 450, 468 

of septum, 293 

of uvula, 339 
Edematous laryngitis, 448 

rhinitis, acute, 156 

rhinitis, chronic, 182 
Elongation of uvula, 337 
Elephantiasis Graecorum, 207 
Embolism, labyrinthine, 597 
Emphysema of antrum of High 
more, 307 

of uvula, 341 
Empyema of frontal sinus, 322 

of maxillary sinus, 302 

of sphenoidal sinus, 316 
Endorhinitis atrophic, 170 
Enlargement of the tonsil, 365 
Epidemic cerebro-spinal menin- 
gitis, 603 

influenza, 144, 149 

influenza, involvement of in- 
ternal ear in, 603 
Epiglottis, 35 
Epiglottitis, acute, 445 

miasmatic, 438 
Epilepsy, neurosis, reflex nasal, 

229 
Epistaxis, 232 

constitutional conditions fav- 
oring, 232 

local causative agents, 232 

traumatic, 232 

vicarious, 232, 234 

systemic, 232, 233 
Epithelioma of auricle, 527 
Equinia, 204, 416 
Ergot, 237, 618 
Erysipelas, acute rhinits in, 

145 

of auricle, 522 

of larynx, 436 
Erythema of nose, 230 
Ethmoid cells, diseases of, 310 
Ethmoidal suppuration, 311 
Ethmoiditis, suppurating, 311 
Euphrasia, 227 
Eustachian canal, 56 

catarrh, 549 

tonsils, 28 

tube, 56 



Eustachian tube, catheterization 
of, 102 

muscles of, 61 
tympanic opening of, 50 
Examination, requisites for, 77, 

86,96 
Examination of ear, physical, 96 
of larynx, 92 
of nose, 80 
of pharynx, 90 
Exostoses of external auditory 

canal, 545 
Exostoses, nasal, 252 
External auditory canal or 
meatus, 528 
diseases of, 528 
examination of, 96 
ear, 45 

otitis, acute circumscribed, 528 
chronic circumscribed, 532 
chronic diffuse, 534 
hemorrhagic, 538 
Extradural abscess, 590 
Exudative pharyngitis, 393 
Eye, affections of as reflex nasal 
neurosis, 229 

False croup, 439, 440, 443 
Fauces and oropharynx, 23 
Fauces, adenoma of, 247 

angioma of, 249 

herpes of, 344 

sarcoma of, 272 
Faucial tonsil, 25, 26, 345. 353 
Fetid coryza, 170 

rhinitis, 170 
Fibrinoplastic rhinitis, 154 
Fibrinous croup, 450 

laryngitis, 450 

tonsillitis, 364 
Fibroma of auricle, 526 

of larynx, 256 

of nasal cavities, 253 

of nasopharynx, 255 

of tonsil, 255 
Fibrous polypi, 261 
Fluxus nasalis, 158 
Follicular laryngitis, 465 

pharyngitis, 397 

tonsillitis, 355 
Folliculous pharyngitis, 397 



Index. 



631 



Foreign bodies in anterior nasal 
cavities, 238 

animate, 238, 241 

inanimate, 238 

rhinoliths, 238 

miscellaneous, 238, 239 

in external auditory canal, 542 

in faucial tonsil, 371 

in larynx, 484 

in pharynx, 429 
Fourth tonsil. 371 
Fossa, Rosenmiiller's, 28 
Frontal sinus, 15 

diseases of, 320 
Functional aphonia, 489 

nervous disorders, auditory 
disturbances in, 610 
Furuncle in external auditory 

canal, 528 
Furnuculosis nasal, 211 



Gangrene of auricle, 523 
Gangrenous inflammation, ng, 
123 

pharyngitis, 385 
Gasoline, 242 
Gelatinous polypi, 262 
Gelsemium, 141, 227, 618 
General symptomatology, 130 
Glanders of maxillary sinus, 307 

nasal, 204 
ulcers in, 218 

of pharynx, 416 
Glycerin, 157, 176, 618 
Gold and sodium chloride, 148, 

293, 617 
Gout, aural complications in, Goo 
Gouty sore throat, 405, 407, 447 

throat, 447 

tonsillitis, 358 
Granular laryngitis, 465 

pharyngitis, 397 
Grindelia, 618 



Hamamelis, 141, 148, 237 
Hay asthma, 224 

fever, 224 
Headache, congestive, 220, 229 
Hearing, artificial aids to, 613 

tests, 106 



Heart, affections of as neuroses. 

reflex nasal, 230 
Helix, anomalies of or malfor- 
mations of, 512 
Hematoma, auris, 522 

of auricle, $22 

of septum, 296 
Hemorrhage, laryngeal, 482 
Hemorrhagia narium, 232 
Hemorrhagic external otitis, 538 

inflammation, 119, 123 
of larynx, 453 

laryngitis, 453 

pharyngitis, 388 
Hereditary syphilis, 193 
Herpes of auricle, 519 

of fauces, 344 

of pharynx, 420 
Herpetic tonsillitis, 359 
Hospital sore throat, 382 
Hydrargyri chloridum corros- 
ivum, 191 

iodidum rubrum, 191 
Hydrastis, 141, 190, 618 
Hydroma, 277 
Hydrorrhea, nasalis, 180 
Hygroma, 2^ 

Hyperemia of labyrinth, 595 
Hyperemia of larynx, 469 
Hyperesthesia of larynx, 488 

of pharynx, 426 
Hyperesthetic rhinitis, 220, 224 
Hyperkeratosis, 423 
Hyperosmia, 220, 221 
Hyperplastic change in the 
pharyngeal structure, 
401 

laryngitis, 468 

nasopharyngitis, 335 

rhinitis, 164 

rhinopharyngitis, 335 

tonsillitis, 365 
Hypertrophic laryngitis, 468 

nasal catarrh, 164 

ozena, 164 

rhinitis, 164 

tonsillitis, 365 
Hypertrophy of laryngeal tis- 
. sue, 468 

of turbinated bones, 164 

of the tonsil, 365 



632 



Index. 



Hysteria, disturbance of audi- 
tion in, 611 
Hysterical aphonia, 489 

Idiopathic or constitutional 
ozena, 170 
membranous croup, 450 
Idiosyncratic coryza, 224 
Ignatia, 162, 618 
Impacted cerumen, 539 
Incisures of Santorini, 47 
Incus, 53 

Infectious diseases, acute, aural, 
complications in, 607 
Igranulomata, 124 

of pharynx, nasopharynx, 
and tonsils, 408 
Infective pharyngitis, 382 
Inflammation, 117 

actinomycosis, 124, 125 
catarrhal, 119, 120 
acute, causes of, 120 
chronic, causes of, 121 
tissue-change in, 120, 121 
chronic infections, 119 
clinical phenomena of, 118 
definition of, 117 
diphtheritic, 119 
gangrenous, 119, 123 
hemorrhagic, 119, 123 
of labyrinth, secondary, 598 
membranous, 119, 122 

croupous or pseudomem- 
branous, 119, 122 
diphtheritic, 119, 122 
fibrinoplastic, 119, 122 
of middle ear, 549 
microscopical phenomena of, 

119 . 
of floor of the nose affecting 

the teeth, 114 
of mucous membrane, 117 
specific, 124, 183 
glanders, 124, 125 
leprosy, 124, 125 
rhinoscleroma, 124, 126 
syphilis, 124 
tuberculosis, 124, 125 
stages of, 118 
suppurative and pustular, 119, 

124 
varieties of, 119 



Inflammatory affections of the 
auricle, 515 

Inflammations, specific, 124 

Inflation of middle ear, methods 
of, 100 

Influence of disease of the nerv- 
ous system and general 
diseases upon the per- 
ceptive apparatus, 606 

Influenza, epidemic, 144, 149 
acute laryngitis in, 438 

Inherited syphilis of the nose, 
I0 3 

Internal ear, involvement of in 
acute infectious dis- 
eases, 602 
syphilis of, 597 

Intertrigo of auricle, 517 

Intubation of larynx, 500 

Intumescent rhinitis, 163 

Iodide of iron, 162 

Ipecac, 436, 445, 619 

Iris, 190, 619 

Jaborandi, 620 
Jamaica dogwood, 620 
June cold, 224 

Keratosis, 423 

Labyrinth, 69 
acute inflammation of second- 
ary to acute purulent 
otitis media, 600 
anemia of, 593 
anatomy of, 45, 69 
hyperemia, 595 
in acute meningitis, 604 
secondary inflammation of, 
following chronic mid- 
dle ear inflammation, 
598 
specific inflammation of, 597 
syphilis of, 597 
the bony, 69 
the membranous, 69, 74 
Labyrinthine embolism and 
thrombosis, 597 
hemorrhage, 596 
Lacunar tonsillitis, 355 
La Grippe, 144, 149 



Index. 



633 



Laryngeal diphtheria, 450 
hemorrhage, 482 
nystagmus, 490 
occlusion, spasmodic, 491 
phthisis, 478 
rheumatism, 447 
spasm, 440, 443 
tissue, hypertrophy of, 468 
tonsil, 345. 37b 
vertigo, 491 
Laryngismus stridulus, 440 
Laryngitis, acute catarrhal, 434 
acute, in children, 439 
acute, in constitutional dis- 
eases, 436 
in erysipelas, 436 
in influenza, epidemic (la 

grippe), 43S 
in measles, 437 
in miasmatic epiglottitis, 

438 
in rheumatism, 439 
in scarlet fever, 437 » 
in small-pox, 437 
in typhoid and typhus fever, 
438 
atrophic, 466 
catarrhal, 443 
croupous, 450 
cyanotic, 468 
dry, 466 
edematous, 448 
fibrinous, 450 
follicular, 465 
glandular, 465 
granular, 465 
henaorrhagic, 453 
hyperplastic, 468 
hypertrophic, 468 
membranous, 450 
phlegmonous, 446, 448 
pseudomembranous, 451 
purulent, 446 
purulent suppurative, 448 
rheumatic, 447 
sicca, 466 

simple chronic, 461 
spasmodic, 440, 443 
specific, 472 
suppurative, 446 
symptomatic, 468 
stridulosa, 443 



Laryngitis, syphilitic, 472 

traumatic, 446 

tubercular, 478 
Laryngorrhea, 434 
Laryngotracheitis, 450 
Larynx, 29 

acute catarrh of, 434 
cellulitis of, 448 

adenoma of, 248 

anatomy of, 29 

anemia of, 469 

anesthesia of, 487 

angioma of, 250 

carcinoma of, 264 

catarrh, simple chronic, 461 

chondritis, 454 

chondroma of, 251 

chorea of, 490 

dilatations or pouches, 432 

diseases of, 431 

edema, chronic, 450, 468 

examination of, 92 

fibroma of, 256 

foreign bodies in, 484 

hemorrhage of, 482 

hyperemia of, 469 

hypertrophies of 432 

intubation of, 500 

laryngismus stridulus, 443 

lipoma of, .256 

lupus of, 433 

malformations and deformi- 
ties of, 431 

mucocele of, 263 

neuralgia of, 489 

papilloma of, 245 

pemphigus, 470 

perichondritis, 454 

sarcoma of, 275 

spasm of in adults, 442 
of in children, 441 

spastic paraplegia, 491 

suppuration of, 446 

surface landmarks of, 30 

syphilis of, 472 

tuberculosis of, 478 

trachoma of, 470 
Lepra, 207 
Leprosy, nasal, 207 
Leukemia, aural involvement 

in, 608 
Lime, 148 



634 



Index. 



Lingual tonsil, 345, 37* 
Lipoma of auricle, 527 

of larynx, 256 

of nares, 256 

of nasopharynx, 256 

of pharynx, 256 
Liquor arseni et hydrargyri io- 

didi, 619 
Liquor potassii arsenitis, 141, 

619 
Lobelia, 619 

Lobule, anomalies or malforma- 
tions of, 512 

thickening of, 523 
Ludwig's angina, 392 
Lupus of auricle, 521 

nasal, 201 

of pharynx, 410 

stenosis of larynx in, 432 
Luschka's bursa, 346 

tonsil, 345, 346 

Malformations and deformities 
of larynx, 431 ' 
of pharynx, 378 
of nasal spaces, congenital, 

281 
of septum, 281 
of uvula, 337 
Maliasmus, 204 

Malignant tumors of auricle, 527 
Malleus, 204 
humidus, 204, 416 
of ear, 53 
Mastoid, 574 
inflammation of, 578 
operation, 582 
process, anatomy of, 574 
Mastoiditis, 578 

Materia medica and therapeu- 
tics, 614 
Maxillary sinus, diseases of, 298 
Measles, acute rhinitis concomi- 
tant with onset, 142 
laryngitis, acute in, 437 
nasal ulcers in, 219 
Membrana flaccida, 59, 99 
tympani, 57, 65 

characteristics of, 99 
color of, 99 
diseases of, 547 
folds of, 58 



Membrana tympani, function of, 

5.7 

injuries of, 547 

vibrans, 99 
Membrane, Shrapnell's, 59 
Membranous croup, 451 
labrinth, 69 
laryngitis, 450 

inflammation of faucial ton- 
sil, 364 
pharyngitis, 384 
rhinitis, 151 

sore throat simple, 420 
tonsillitis, 364 
Menstruation, epistaxis as vi- 
carious, 232, 234 
Metastatic aural involvement, 607 
Miasmatic epiglottitis, 438 
Microtia, 512 

Middle ear, acute catarrhal in- 
flammation of 553 
acute purulent inflammation 

of, 561 
chronic catarrhal inflamma 

tion of, 567 
chronic purulent inflammation 

of, 561 
diseases of, 547 
inflammation of, 549 
Migraine, neuroses, reflex nasal, 

229 
Miller's asthma, 440 
Mogiphonia, 487 
Mucocele of ethmoid cells, 314 

of larynx, 263 
- of nasal cavities, anterior, 2C2 

or nasopharynx, 262 
Mucous croup, 443 
Mucous membrane of accessory 
sinuses, 17 
of anterior nasal cavities, 17 
inflammation of, 117 

varieties of, 119 
membranes and their patho- 
logical changes, 112 
structure of, 115 
polypi, 262 
Mumps, aural complications in, 

603 
Muscles of the ear, 60 
of the Eustachian tube, 61 
intratympanic, 60 



Index. 



635 



Mycosis of faucial tonsil, 370 

of lingual tonsil, 375 

of uvula, 341 
Myringitis, 548 
Myxocarcinoma, 276 
Myxofibroma, 261 
Myxoma of nasal cavity, 258 

of sphenoid cells, 319 

Naphthaline, 227 

Nasal actinomycosis, 210 

alae, collapse of, 289 

bacteria, 126 

blenorrhea, acute, 135 

breathing, importance of, in 

calculi, 238 

cartilages, depression of, 296 

catarrh, acute, 135 
atrophic, 170 
chronic, 158 

cavities, anterior, adenoma of, 

247 

anatomy of, 10 

angioma of, 248 

carcinoma of, 264 

chondroma of, 250 

cysts, 276 

examination of, 80 

exostosis of, 252 

fibroma of, 253 

fibrous polypi, 261 

foreign bodies in, 238 

gelatinous polypi, 262 

hematoma of septum, 296 

histology of mucous mem 
brane, 17 

lipoma of, 256 

mucocele, 262 

mucous polypi, 262 

myxofibroma, 261 

myxoma, 258 

osteoma, 2S7 

polypus, 258 

sarcoma, 270 

septum, diseases of, 278 
edema, 293 
perforation 0*f, 292 
ulceration of, 290 

malformation of, 281 

olfactory region, 17, 18 

papilloma of, 244 

ulcers of, 213 

vestibule a part of, n 



Nasal concretions, 238 

deformities, correction of, 284 

diphtheria, 154 

focsse, 10 
x glanders, 204 

hydrorrhea, 180 

leprosy, 207 

lupus, 201 

neuroses, 220 

phthisis, 196 

polypus, 258 

syphilis, 183 

tonsil, 345 

tuberculosis, 196 
Nasopharyngitis, acute, 328 

atrophic, 333 

hyperplastic, 335 

simple chronic, 330 
Nasopharynx, adenoma of, 247 

anatomy of, 21, 22 

boundaries, 21 

carcinoma of, 265 

chondroma of, 251 

fibroma of, 255 

lipoma of, 256 

mucocele of, 262 

papilloma of, 245 

sarcoma of, 271 
Neoplasms, 243 

adenocarcinoma, 276 

adenoma of anterior nares, 247 
of fauces, 247 
of larynx, 248 
of nasopharynx,* 247 

angioma, of fauces, 249 
of larynx, 250 
of nasal cavities, 248 
of pharynx and uvula, 250 
of tonsil, 250 

carcinoma of nasal cavity, 264 
of nasopharynx, 265 
of pharynx, 266, 268 
of soft palate and uvula, 266 
of tonsil, 268 

chondroma (enchondroma) of 
larynx, 251 
of nasal cavities, 250 
of nasopharynx, 251 

classification of, 243 

cysts, cystoma, 277 
dermoid, 277 

simple or retention (muco- 
cele), 276 



6 3 6 



Indkx. 



Neoplasms, exostoses, 252 
fibroma of larynx, 256 
of nasal cavities, 253 
of nasopharynx, 255 
of tonsil, 255 
fibrous polypi (myxofibroma), 

261 
lipoma of larynx, 256 
of nares, 256 
of nasopharynx, 256 
of pharynx, 256 
mucocele, 262 
myxocarcinoma, 276 
myxoma (nasal polypus), 258 
of upper respiratory tract, 24.3 
osteoma of nares, 257 
papilloma of larynx, 245 
of nares, 244 
of nasal cavity, 244 
or nasopharynx, 245 
of pharynx, 245 
polyp, fibrous nasal, 261 
sarcoma of fauces, pillars., and 
soft palate, 272 
of larynx, 275 
of nasal cavities, 270 
of nasopharynx, 271 
of pharynx, 273 
of tonsil, 274 
teratoma, 276 
Nephritis, aural affections in, 

607 
Nerve, auditory, 75 
Nervous cough, 486 
Neuralgia of larynx, 489 
of pharynx, 427 
supraorbital, 229 
Neurasthenia, impairment of 

hearing in, 610 
Neuroses of larynx, 486 
anesthesia, 487 
chorea, 490 
hyperesthesia, 488 
mogophonia, 487 
paresthesia, 488 
Neuroses, nasal, 220 
of olfaction, 220 
anosmia, 220, 221 
hyperosmia, 220, 221 
parosmia, 220 
of nasopharynx, 336 
of pharynx, 426 



Neuroses, reflex nasal, 220 
hydrorrhea as, 220 
non respiratory, ear, 220 
aprosexia, 229 
chorea, 220, 229 
epilepsy, 220, 229 
eye, 220 
headache, congestive, 220, 

229 
migraine, 220, 229 
neuralgia, 220, 229 
neuralgia, supraorbital, 229 
of heart, 220 
of sexual organs, 220 
of stomach, 220 
tic douloureux, 229 
vertigo, 229 
respiratory, asthma, 220, 228 
cough nasal, 220 
hydrorrhea, 220 
of larynx, 220, 228 
aphonia, 228 
spasm, 228 
of pharynx and mouth, 220, 

228 
rhinitis, hyperesthetic, 220, 

224 
of rhinopharynx, 336 
sneezing, 220, 223 
Nose-bleed, 232 
Nux vomica, 141, 162, 237, 619 

Obstruction of nasal cavities. 

causes of, 278 
Obstructive rhinitis, 164 
Occupation pharyngitis, 386 

rhinitis, 155 
Ointment of salicylic acid, 146, 

161 
Olfactory nerves, 20, 21 
Oropharynx and fauces, 23, 24, 

25 
Osseus meatus, 47 
Ossicles, the, 52 
Ossification of the auricle, 523 
Osteoma of nasal cavities, 257 

of sphenoid cells, 319 
Ostium maxillare, 15, 16 
Othematoma of auricle, 522 
Otitic meningitis, 588 
Otitis, acute circumscribed, 528 

acute diffuse external, 532 



Index. 



637 



Otitis, chronic circumscribed ex- 
ternal, 532 
diffuse external, 534 
externa circumscripta acuta, 

528 
external, croupous and diph- 
theritica, 538 
media, catarrhalis, acute, 553 
acute purulent, 557 
catarrhalis chronica, 567 
purulenta, 557 
purulenta residua, 565 
chronic catarrhal, 567 
hyperplastic, 571 
hypertrophic, 568 
chronic purulent, 561 
chronica, 561 
Otosclerosis, 571 
Ozena, 169, 170 
laryngis, 466 

Pachydermia laryngis, 470 
Papilloma of auricle, 527 
of nares, 244 
of nasal cavity, 244 

of nasopharynx, 245 
of larynx, 245 
of pharynx, 245 
Paraffin injections for nasal de- 
formities, 192 
Paralysis, acute bulbar of soft 
palate, 343 
apoplectiform bulbar of soft 

palate, 344 
chronic bulbar of soft palate, 

343 
soft palate, 343 
uvula, 343 
of vocal cords, 492 
table of, 498 
Paresthesia, larynx, 488 

of pharynx, 426 
Parosmia, 220 
Peach cold, 224 
Pemphigus of auricle, 519 

of larynx, 470 
Perceptive mechanism of car, 
diseases of, 593 
effect of diseases of general 
nervous system upon, 
606 



Perceptive mechanism of ear, 
involvement of in acute infec- 
tious diseases, 602 
Perforation of septum, 292 
Perichondritis of auricle, 521 

of larynx, 454 
Periodical hyperesthetic rhinitis, 

224 
Peritonsillar or tonsillar ab- 
scess, 360 
phlegmon, 360 
Pertussis, 144 

Pharyngeal bursa, catarrh of, 
330 
nystagmus, 427 
tonsil, 28, 345, 346 
Pharyngitis, acute rheumatic, 

405 

atrophic, 402 

catarrhal, 380 

chronic rheumatic, 407 

croupous, 384 

exudative, 393 

follicular, 397 

gangrenous, 385 

granular, 397 

hemorrhagic, 388 

herpetica, 420 

hypertrophica lateralis, 401 

infective, 382 

membranous, 384 

occupation, 386 

phlegmonous, 382 

sicca, 402 

simple acute, 380 
membranous, 384 
chronic, 393 

subacute, 397 

suppurative, 382 

traumatic, 386 
Pharyngomycosis, 421 
Pharynx, abscess, retropharyn- 
geal, 418 

actinomycosis of, 416 

anatomy of, 2J 

anemia of, 425 

anesthesia of, 426 

angioma of, 250 

carcinoma of, 266, 268 

diseases of, 277 

diverticula or dilatation, 379 

dome or vault of, 10, 27 



638 



Index. 



Pharynx, ecthyma of, 420 

erythema of in exanthemata 
and other fibrile condi- 
tions, 389 
Pharynx, foreign bodies in, 429 

glanders in, 416 

herpes of, 420 

hyperesthesia of, 426 

hyperplastic change in, 401 

infectious granulomata, 408 

lipoma of, 256 

Ludwig's angina, 392 

lupus of, 410 

malformations and defornu 
ties, 378 

neuralgia of, 427 

neuroses of, 426 
of motion, 426, 427 

papilloma of, 245 

paresthesia of, 426 

pharyngomycosis, 421 

pulsating arteries of, 424 

sarcoma of, 273 

spasm of, 427 

syphilis of, 412 

tuberculosis of, 408 

urticaria of, 420 

vault of, 10 
Phlegmonous rhinitis, 157, 211 

laryngitis, 446, 448 

pharyngitis, 382 

tonsillitis, 360 
Phthisis nasalis, 196 
Phytolacca, 141, 148, 619 
Physostigma, 619 
Pituitary membrane, 17 
Pollen catarrh, 224 
Polyp fibrous nasal, 261 
Postnasal catarrh, acute, 328 
chronic, 330 

cavity, or space, 10, 21 
Potassium bichromate, 141, 14S, 
620 

iodide, 190, 620 

permanganate, 191 
Preglottic tonsillitis, 372 
Primary pseudomembranous 

rhinitis, 151 
Pruritic rhinitis, 224 
Pseudocroup, 443 
Pseudomembranous croup, 451 

laryngitis, 451 



Pulsatilla, 141, 620 

Pulsating arteries of the 

pharynx, 424 
Purulent ethmoiditis, 311 

inflammation of middle ear, 
acute, 557 
chronic, 561 
laryngitis, 446 
nasal catarrh, 179 
rhinitis, 179 

suppurative laryngitis, 448 
Putrid sore throat, 385 

Quinine, 620 
Quinsy, 360 

Rag-weed fever, 224 
Recurrent laryngeal paralysis, 

493. 
Red mercuric iodide, 191 
Reflex aural disturbances, 229, 
611 

nasal neuroses, 220, 223, 229 
Relation of general diseases to 
the upper respiratory 
tract, 130 
Respiratory neuroses, 223 
Retronasal catarrh, acute, 328 

chronic, 330 
Retro-pharyngeal abscess, 418 
Rheumatic angina, 405 

laryngitis, 447 

pharyngitis, 407 

sore throat, 405 

tonsillitis, 358 
Rheumatism, 144 

acute laryngitis in, -439 

aural complications in, 609 

chondritis and perichondritis 
of larynx in, 455, 458 

nasal ulcers in, 219 
Rhinitis, acute, 135 

simple edematous, 156 

anemic, 145 

atrophica, 170 
simplex, 170 

caseosa, 149 

catarrhalis, 135 

chronica, 158 

croupous, 151 

cyanotic, 182 

diphtheritic, 154 



Index. 



639 



Rhinitis, edematosa chronica, 182 

edematous, acute, 156 
chronic, 182 

fetid, 170 

fibrinoplastic, 154 

foetida atrophica, 170 

hyperesthetica, 220, 224 

hyperplastic, 164 

hypertrophic, 164 

idiopathic acute, 135 

intumescent, 163 

membranous, 151 

obstructive, 164 

occupation, 155 

phlegmonous, 211 

pseudomembranous, 151 

purulent, 179 

sclerotic, 170 

scrofulous, 146 

sicca, 170 

simplex, 158 

simple chronic, 158 

strumous, 146 

syphilitic, 183 

traumatic, 155 
Rhinoliths, 238 
Rhinopharyngitis, acute, 328 

atrophic, 333 

chronic, 330 

hyperplastic, 335 
Rhinorrhagia, 232 
Rhinorrhea, acute, 135 
Rhinorrhea, 180 

chronic, 158 
Rhinoscleroma, 210 
Rhus tox, 621 
Rose catarrh, 224 

cold, 224 

fever, 224 
Rosenmuller, fossa of, 28 

Saccule, the, 74 
Salicylated boric acid, 153 
Salicylic acid ointment, 146 615, 

wash, 146, 148, 616 
Salpingitis,, acute, 549 
Santonine, 215 
Sarcoma of auricle, 527 

of fauces and soft palate, 272 

of larynx, 275 

of nasal cavities, 270 



Sarcoma of nasopharynx, 271 
of nharynx, 273 
of sphenoid cells. 319 
of tonsil, 274' 
Scarlet fever, acute rhinitis in, 
144 
laryngitis acute in, 437 
nasal ulcers in, 219 
Schneiderian membrane, 17 
Sclerotic rhinitis, 170 
Scorbutic rhinitis, 145 
Scrofulous ozena, 146 

rhinitis, 146 
Secondary atrophy resulting 

from other lesions, 177 
Secondary inflammation of 

labyrinth, 598 
Semicircular canals, 70 
Septum, abscess of, acute/ 294 
chronic, 295 
anatomy of, 10 
deflection and deviation, treat- 
ment, 284 
edema of, 293 
hematoma of, 296 
malformations of, 281 
perforation of, 292 
submucous infiltration, 293 
ulceration of, 290 
Sexual disorders, organs, affec- 
tions of, as reflex nasal 
neuroses, 230 
Shrapnell's membrane, 59 
Silicea, 177 
Silver nitrate, 190 
Simple acute pharyngitis, 380 
rhinitis, 135 

in some of the constitu- 
tional diseases, 142 
catarrh, 135 
chronic laryngitis, 461 
nasal catarrh, 158 
nasopharyngitis, 330 
pharyngitis, 393 
rhinitis, 158 
rhinopharyngitis, 330 
membranous pharyngitis, 384 
or retention cyst, 276 
ozena, 170 
rhinitis, 170 
sore throat, 420 
Singer's nodules, 470 



640 



Indkx. 



Sinus thrombosis, 589 
Sinuses accessory, 13 
Sinuses, accessory, diseases of, 
298 
ethmoid, anatomy of, 15 
catarrhal inflammation of, 

3io, 3ii 
diseases of, 310 
mucocele, 314 

and non-infected fluid-re- 
tention, 314 
specific inflammations, 315 
suppurating ethmoiditis, 311 
tumors, 315 
frontal, anatomy of, 15 
catarrhal inflammation, 

acute, 320 
chronic, 321 
diseases of, 320 
empyema of, 322 
acute purulent inflamma- 
tion, 322 
chronic purulent inflamma- 
tion, 323 
chronic suppurative inflam- 
mation, 323 
confined suppuration, 323 
foreign bodies, 326 
infectious conditions, 327 
mucous membrane of, 17 
mucocele, 325 
tumors, 327 . 
maxillary, actinomycosis of, 

3°7. 
acute infectious diseases, 

307 

anatomy of, 15, 16 

catarrhal inflammation, 
acute, 298 
inflammation, chronic, 
chronic, 300 

cysts, 310 

diseases of, 298 

emphysema, 307 

empyema of, 302 

acute purulent inflamma- 
tion, 302 

chronic purulent inflamma- 
tion, 303 

confined suppuration, 304 

foreign bodies, 308 

glanders of, 307 



Sinuses, maxillary, mucocele of, 

309 

ozena of, 301 
phlegmonous inflammation 

310 
syphilis of, 307 
tuberculosis of, 307 
tumors of, 309 
sphenoidal, acute infections, 
319 
anatomy of, 13 
catarrhal inflammation, 316 
diseases of, 315 
empyema, 316 
mucocele, 319 
syphilis, 319 
tuberculosis, 319 
tumors, 319 
Small-pox, 144 
acute laryngitis in, 437 
nasal ulcers in, 219 
Sneezing, 220, 223 
Snuffles, 135 

Soft palate, adhesions, 341 
carcinoma of, 266 
diseases of, 337 
herpes, 344 
neuroses, 342 

neuralgia, 342 
paralysis, 343 
acute bulbar, 343 
apoplectiform bulbar, 344 
chronic bulbar, 343 
spasmodic contraction, 343 
sarcoma of, 272 
Solution, alkaline, 148 
Spasm of abductors of vocal 
cords, 440 
of glottis, 440 
of glottis in adults, 442 

in children, 441 
of larynx, 440, 443 
in adults, 442 
in children, 441 
of pharynx, 427 
Spasmodic croup, 439, 440, 443 
laryngeal occlusion, 491 
laryngitis, 440, 443 
Spasmus glottidis, 440 
Spastic paraplegia of the larynx, 
491 



Index. 



641 



Specific catarrh, 183 
granulomata, 124 
inflammation of labyrinth, 597 
inflammations, 124, 183 
inflammatory processes, 124, 

183 
laryngitis, 472 
rhinitis, 183 
Sphenoidal sinuses, 13 
Spurious croup, 434, 443 
Staphylococci found in normal 

nose, 127 
Stearate of zinc with europhen, 

. I 4 I . . 
with salicylic acid, 204 
Stenosis of larynx, 432 
Sticta, 142, 228, 621 
Stomach, affections of as reflex 

nasal neuroses, 230 
Stridnlous angina, 443 

laryngitis, 443 
Stropanthus, 621 
Strumous rhinitis, 146 
Strychnine sulphate, 621 
Subacute pharyngitis, 397 
Submucous infiltration of sep- 
tum, 293 
Summer catarrh, 224 
Suppuration of larynx, 446 
Suppuration of middle ear, 
acute, 5=7 
chronic, 561 
Suppurative otitis media, 561 
laryngitis, 446 
pharyngitis, 382 
or pustular inflammation, 119, 

I2 4 
Suprarenal derivatives, 141 
Surface landmarks of larynx, 30 
Symptomatic laryngitis, 468 
Syphilis, cause qf chondritis of 
larynx, 455, 456 
larynx, 472 
nasal, acquired, 183 

hereditary, 183, 193 
pharynx, primary, 412 
secondary, 413 
tertiary, 414 
of auricle, 520 
of labyrinth, 597 
tarda, 193 



Syphilitic ozena, 183 

rhinitis, 183 
Syrup iodide of iron, 621 



Teratoma, 276 
Third tonsil, 28 
Thrombosis, labyrinthine, 597 
Thuja, 177, 190, 621 
Thymic asthma, 440 
Tic douloureux, 229 
Tonsil buccal, 371 
Tonsils, anatomy of, 25, 26 
angioma of, 250 
buccal, 371 
carcinoma of, 268 
chronic abscess of, 370 
classification of, 345 
discrete. 346 
Eustachian tonsils, 28 
faucial, 345 

abscess, chronic, 370 

tonsillar or peritonsillar, 
360 
atrophy, 370 

cryptic tonsillitis, 355 
diseases of, 353 
hypertrophy of, 365 
foreign bodies in, 371 
membranous inflamma- 
tion of, 364 
mycosis, 370 
tonsillolith, 370 
fibroma of, 255 
infectious granuloma of, 408 
fourth, 371 
laryngeal, 345, 37& 

anatomy of, 28 
lingual, 345 

acute inflammation, 372 
acute phlegmonous inflam- 
mation of, 373 
classification of diseases of, 

37i 

hyperplasia of, 374 

mycosis of, 375 

varices of, 375 
Luschka's tonsil, 346 
nasal, 345 

pharyngeal, 28, 345, 340 

sarcoma of, 274 

tubal, 345 



642 



Index. 



Tonsillitis, acute catarrhal, 354 

superficial, 354 

caseous, 369 

cryptic, 355 

fibrinous, 364 

follicular, 355 

gouty or rheumatic, 358 

herpetic, 359 

hyperplastic, 365 

hypertrophic, 365 

lacunar, 355 

membranous, 364 

parenchymatous, 356 

phlegmonous, 360 

preglottic, 372 

superficial acute, 354 

suppurative, 124 

ulcerative, 364 
Tracheotomy, 505 ' 
Trachoma, 470 

Trachoma of vocal cords, 470 
Tragus, anomalies or malfor- 
mations of, 512 
Traumatic laryngitis, 446 

pharyngitis, 386 

rhinitis, 155 
Traumatism, causing chondritis 
and perichondritis of 
larynx, 456, 458 
True croup, 451 
Tubal catarrh, 549 

congestion, 549 

tonsil, 345 
Tube, Eustachian, 56 

Congestion of, 549 
Tubercular laryngitis, 478 
Tubercular rhinitis, 146 
Tuberculosis, aural involvement 

in, 608 
Tuberculosis as cause of chon- 
dritis . of larynx, 455, 456 

of larynx, 478 

of nasopharynx, 408 

nasalis, 196 

of pharynx, 408 
Tubercular laryngitis, 478 
Tubo-tympanic catarrh, 552 

congestion, 552 
Tubotympanitis. 552 
Tumors of auricle, benign, 525 

malignant, 525, 527 
Turbinates, 11 



iympanic cavity, 49 
membrane, 57 
muscles, 60 
opening of Eustachian tube, 

5o 
Typhoid fever, acute laryngitis 

in, 438 
chondritis and perichondritis 

in, 455, 457 _ 
involvement of internal ear 

in, 603 
nasal ulcers in, 219 
Typhus fever, acute laryngitis 

in, 438 
involvement of internal ear 

in, 603 
nasal ulcers in, 219 

Ulceration, nasal, 213 

of septum, '290 

of uvula, 340 
Ulcerative sore throat, 382 

tonsillitis, 364 
Ulcers, nasal, 213 
* compound malignant, 213, 217 

croupous or^fibrinous, 219 

diabetic, 213, 216 

diphtheritic, 219 

due to foreign bodies, 213,215 
glanders, 218 

eczematous, 213, 214 

herpetic, 213, 214 

infected, 213, 217 

leprous, 213, 218 

measles, 219 

neuroparalytic, 213, 215 

scrobutic, 213, 216 

simple, 214 

simple catarrhal, 213, 214 

syphilitic, 213, 218 

tubercular (lupoid), 213, 217 

varicose, 213, 2l6 
Urticaria of nose, 230 
Urticaria of pharynx, 420 
Uvula, acute abscess of, 340 

infiltration, 339 

adhesion of, 341 

angioma of, 250 

diseases of, 337 

edema of, 339 

elongation of, 337 

emphysema of, 341 



Ind£x. 



643 



Uvula, malformations of, 337 
mycosis of, 341 
paralysis of, 343 
ulceration of, 340 
uvulitis, acute, 339 
chronic, 340 

Varices of lingual tonsil, 375 
Variola, 144 
Vault of pharynx, 10 
Velum, neuroses of, 342 
Veratrum, 237, 621 



Vertigo, neuroses, reflex nasal, 

229, 230 
Vestibule of ear, 69 
Vestibule of nose, 11 
Vicarious epistaxis, 232, 234 
Vocal cords, 38 

paralysis of, 492 
Voice user's sore throat, 393 

Wash, alkaline, 148 

salicylic acid, 146, 148, 616 
Whooping cough, 144 
Wounds of auricle, 515 




DESCRIPTIVE CATALOGUE 

AND 

PRICE LIST 

OF 



Eclectic Text-Books 



FOR SAIvF BY 



THE SCUDDER BROS. CO. 

MEDICAL PUBLISHERS, 
1009 Pkim Street, CINCINNATI, O. 



AS a school of medicine we profess to have a distinctive practice un- 
like either our old school or homoeopathic neighbors. We claim to 
use different remedies, or in different form and dose, and for differ- 
ent effects. We boldly claim a more successful practice than either 
of our competitors, and this claim can only be based upon different prin- 
ciples, a different therapeutics, and a different materia medica. 

We must, therefore, have distinctive books which clearly state ozir 
methods of practice. Old-school works will not serve this purpose, neither 
will homoeopathic. With the pretensions we make, if we can. not show 
that we have such works, and depend on them, we are frauds of the first 
magnitude. 

Now we have a full list of text-books, or books of reference, and by 
frequent revision they are kept fully up to our practice of to-day. They 
have been very successful, more so than any American books in the market, 
and this is the best evidence of their value. They are bought by all schools 
of medicine, and when bought they are brought into active use. 

Special Note. — The prices as given in this catalogue are absolutely 
net, no discount will be allowed retail purchasers under any consideration. 
This rule has been established in order that every one will be treated alike, 
a general reduction in former prices having been made to meet previous 
retail discounts offered by some dealers. Upon the receipt of the advertised 
price any book will be forwarded by mail or express, all charges prepaid. 



ECLECTIC TEXT-BOOKS. 



COOPER, WM. COLBY, M. D. 

t Tethered Truants. 

i2mo, 199 pages, Price, cloth, $1.00 

Being Essays, Sketches and Poems. 

1 Immortality. 
i2mo, 173 pages, Price, cloth, $1.00 

f Preventive Medicine. 
i2mo, 147 pages, Price, cloth, $1.00 



ELLINGWOOD, FINLEY, M. D. 

Professor of Materia Medica in the Bennett College of Eclectic Medicine, 
and editor of the Chicago Medical Times. 

1 Eclectic Materia Medica and Therapeutics, 

Royal octavo, 811 pages. (Revised 1905), . Price, cloth, $5.00 ; sheep, $6.00 

About 450 remedies. Every subject of interest before the profession to- 
day in Therapeutics considered. The Department of Pliamiacy and Phar- 
macognosy, bv PROF. JOHN URI LLOYD, Ph. M., Ph. G. Five other promi- 
nent eclectic writers. PKOF. FINLEY ELIJNGWOOD, editor ol the Times, 
has been quietly at work on this book for five years and has it now ready for 
distribution. 



FARNUM, EDWARD J. t M. D. 

Professor of Surgery in the Bennett Medical College of Chicago. 

1 Deformities. 

Royal octavo, 554 pages, 208 illustrations, enameled paper, cloth 

binding. (Issued 1898), Price, $5.00 net, postpaid 

A text-book on Orthopedic Surgery. Contributors: EDWIN FREE- 
MAN, M. D., Cincinnati ; EDWIN YOUNKIN, M. D., St. Louis. 



FELTER, HARVEY W., M. D., 

AND 

LLOYD, JOHN URI, Phr. M. 

t American Dispensatory (King.) 

(Revised in 1900) Entirely rewritten and enlarged by HARVEY W. 
FELTER, M. D., Professor of Anatomy in the Fclectic Medical Institute, 
Cincinnati, O. ; editor Locke's Materia Medica and Therapeutics; President 
Ohio State Eclectic Medical Association, etc., and JOHN URI LLOYD, 
Phr. M., Prolt-ssor of Chemistry and Pharmacy in the Eclectic Medical Insti- 
tute, Cincinnati, O., formerly Professor of Pharmacy in the Cincinnati Col- 
lege of Pharmacy; ex-President of the American Pharmaceutical Associa- 
tion ; author of the Chemistry of Medicines, Drugs and Medicines of North 
America, Etidorhpa, etc. 

Two-volume edition, Royal octavo, each volume containing over 
950 pages, with complete indices. 

Price, cloth, $450 per volume ; sheep, $5.00 per volume, postpaid 



ECLECTIC TEXT-BOOKS. 



FYFE, JOHN WILLIAM, M. D. 

* The Essentials of Modern Materia Medica and Therapeutics. 

With Formulary by G. W. Boskowitz, M. D., i2mo, 344 pages. 

(Issued in 1903), • Cloth, $2.00 

The introduction is at once complete, compact and comprehensive. 
While nothing supcifluous is presented, nothing important has been omitted. 
The action of" medicines, strength, dose, prescription writing, dispensing, 
incompatibility, etc., are each and all carefully and wisely treated. We like 
the tone of this book : it is decidedly refreshing, refreshing^ decided, con-* 
servative without being narrow, liberal without lapsing into promiscuous 
carelessness and wholesale commendation. For the working practitioner, 
the busy, every-day doctor, the man of few spare moments and fewer idle 
ones, we think the general verdict will be Eureka. — Georgia Eclectic Med- 
ical Journal. 



FOLTZ, KENT O., M. D. 

Professor of Ophthalmology, Otology, Rhinologj', and Laryngology, 
in the Eclectic Medical Institute, Cincinnati. 

* Diseases of the Eye. 

i2mo, 566 pages, fully illustrated. (Issued in 1900), . Price, cloth, $2.50 

A complete manual on the subject for the use of students and Prac- 
titioners. This is the first work on this subject which gives particular at- 
tention to the treatment of diseases of the eye by Eclectic medication. 

* Diseases of the Nose, Throat, and Ear. 
i2mo, over 700 pages, fully illustrated. (Issued 1906), . Price, cloth, $3.50 

This is a companion work to " Diseases of the Eye," but 
somewhat larger and more comprehensive. 



GOSS, I. J. M., M. D. 

Late Professor of Practice of Medicine in the Ga. College of Eclectic 
Medicine and Surgery. 

t The Practice of Medicine ; or the Specific Art of Healing. 
8vo, 569 pages. (Revised 1897), Price, cloth, $1.50 



HOWE, A. JACKSON, M. D. 

Late Professor of Surgery in the Eclectic Medical Institute, Cincinnati. 
"Prof. Howe was recognized as one of the ablest teachers in this country, 
and an operating surgeon with but few peers in the West." 

::: Diagnosis and Treatment of Dislocations and Fractures. 
Fourth edition, Svo, 426 pages, .... Price, cloth, $1.50; sheep, $2.00 

t Operative Gynaecology. 

8vo, 360 pages, Price, sheep, $4.00 

Note.— Neither of these works revised since the author's death in 1 



ECLECTIC TEXT-BOOKS. 



KING, JOHN, M. D. 

Late Professor of Obstetrics in the Eclectic Medical Institute, Cincinnati. 
"Prof. John King\ who was a teacher for more than half a century, is too 
well known to require more than a catalogue of his books." They are as 
follows : 

t The American Dispensatory. 
See revised edition, under head of Felter-Uoyd. 

tThe American Eclectic Obstetrics. 

Ninth edition, 8vo, 757 pages, Price, sheep, $5.50 

Revised, rewritten and enlarged, by R. C. WINTERMUTE, M. D. 

* Diagnosis and Treatment of Chronic Diseases. 

8vo, 1,700 pages, Price, sheep, $8.50 

tThe New American Family Physician. 
8vo, 1,042 pages, Price, morocco, $6.50 

* Woman, Her Diseases and Their Treatment. 

Fourth edition, 8vo, 366 pages, .... Price, cloth, $1.50 ; sheep, $2.00 

Note. — The last three works not revised since author's death in 1893. 

LLOYD, JOHN URI. 

Professor of Pharmacy in the Eclectic Medical Institute, Cincinnati ; Vice- 
President of the American Chemical Society ; Associate Author of the re- 
vised edition of the American Dispensatory ; Author of the Pharmacy and 
Chemistry of the Student's Pocket" Medical Lexicon. 

t Red Head. 
A Story of Feud Life in Kentucky. Edition de luxe, cloth, • . . $1.72 
1 Etidorhpa; or The End of Earth. 
I i2mo, Illustrated. 375 pages. Eleventh edition. Price, cloth, $1.50 

B. O. Fowler, editor of " The Arena," Boston, says: " A most remark- 
able book. * * Surpasses, in my judgment, anything that has been 
written by the elder Dumas or Jules Verne, while in moral purpose it is 
equal to Hugo at his best. * * It appeals to the thoughtful scientist no 
less than to the lover of fascinating iomance." 

t Stringtown on the Pike. 
Price, by mail, $1.50 

A character study of the people of Northern Kentucky. It embraces the 
superstitions, methods and acts of these people, and is most reliable in its 
study of human emotions and methods. Fully illustrated with engravings 
of the people of " Stringtown on the Pike." Judge T. Soule Smith, of Lex- 
ington, the best writer in the State, remarks: "No such vivid landscape 
painting- of Kentuckv seasons and Kentucky scenery is to be found in any 
book. The book is a" drama of real life under conditions which necessarily 
make it dramatic. 

The editor of "The New Idea," says: "The story is a masterpiece of 
dialect study." 

t Warwick of the Knobs. 
i2mo, 305 pages, Cloth, $1.50 

t Scroggins. 
j2tno, 119 pages, . , . , ,.,.,,,.... , -Price, cloth, $1.50 



ECLECTIC TEXT-BOOKS. 



LOCKE, FREDERICK J., M. D. 

I,ate Dean and Professor of Materia Medica and Therapeutics in the Eclectic 
Medical Institute, Cincinnati, Ohio. 

FELTER, HARVEY W., M. D., Collaborator. 
Professor of Anatomy in same. 

* Syllabus of Eclectic Materia Medica and Therapeutics. 

Second edition. (Revised in 1901.) i2mo, 501 pages, . Price, cloth, $2.50 

" We have examined this work with great care, and find it full}' up to the 
standard of the works of the Eclectic School. We do not propose to take 
this as an opportunity to give a lecture on the advisability ot continuing 
self-limited sectarianism in medicine — our views on this subject are already 
well known to our readers. We have, however, never read a medical book, 
even a sectarian one, without receiving benefit from it. Every practitioner 
should study the therapeutic principles of every school of medicine. He 
should make the best from each one— the everlasting truth— his own. This 
book before us cgntains much that is of value. The Eclectic practitioners 
deserve lasting credit for having developed the therapeutic virtues of many 
of our common American plants. This is honor enough for one sect in one 
country."— Medical World. 

MUNDY, WILLIAM NELSON, M. D. 

Formerly Professor of Physical Diagnosis, Hygiene and Diseases of Chil- 
dren in the Eclectic Medical Institute. 

*The Eclectic Practice in the Diseases of Children. 

For students and practitioners. i2mo, 631 pages. (Issued in 

1902), Cloth, $2.50 



MUNK, J. A., M. D. 

Dean of Los Angeles Eclectic Polyclinic. Editor Los Angeies Journal of 
Eclectic Medicine. 

t Arizona Sketches. 
Octavo, 230 pages, full}' illustrated, Price, Cloth, $2.00 

NIEDERKORN, JOSEPH S., M. D., Versailles, O. 

t A Handy Reference Book to Specific Medication. 
i6mo, pocket size, 151 pages. (New edition, 1905), . Price, flexible leather, $1.25 



PETERSEN, F. J., M. D., Lompo, Cal. 

Materia Medica and Clinical Therapeutics. 
i2mo, 400 pages. (Issued in 1905), Price, cloth, $3.00 

SCUDDER, JOHN M., M. D. 

Late Professor of the Practice of Medicine in the Eclectic Medical Institute, 
Cincinnati. 

Note. — None of Professor Scudder's eight works have been revised since his 
death in 1S94. 

* The Eclectic Practice of Medicine. 

Fourteenth edition revised. 8vo 816 pages. 

Price, cloth, $4.50 ; sheep, $5,00 



6 ECLECTIC TEXT-BOOKS. 

SCUDDER, JOHN M., M. D.— Continued. 

*The Principles of Medicine. 
Sixth edition. 8vo, 350 pages, Price, cloth t $J.50 ; sheep, $2.00 

This is a study of the elements of disease and the principles of cure. It 
is the basis of our practice, and as we think, the practice of the future. It 
gives a rational basis for medical practice. 

:i: The Eclectic Practice in Diseases of Children. 
Seventh edition. 8vo, 486 pages, . . . Price, cloth, $2.50 ; sheep, $3.00 

If there is one thing: more than another that we take pride in, it is our 
success in the treatment of children. The teaching of pleasant remedies, in 
small doses, for direct effect has relieved thousands of children from the 
horrors of " regular " medicine. 

* A Practical Treatise on the Diseases of Women, 

Illustrated by colored plates and numerous wood engravings, with 
a paper on Diseases of the Breasts. Fifteenth edition, re- 
vised. 8vo, 534 pages, Price, cloth, $2.75 ; sheep, $3.50 

This work has stood the test of thirty years, and, as revised, gives our 
treatment of to-day. 

* Specific Medication and Specific Medicines. 
Fourteenth edition, fourth revision. i2tno, 432 pp., . Price, cloth, $2.00 

'*' Specific Diagnosis. 

Ninth edition. i2mo, 388 pages, Price, cloth, $J.50 

These companion volumes have had a larger sale than any other med- 
ical works in this country. They appeal to the feeling every thinking phy- 
sician cherishes, that there must be something certain in medicine, if it can 
be discovered. They have had a very marked influence upon medical prac- 
tice, not only of our own school, but also on regular medicine and homoe- 
opathy. 

* The American Eclectic Materia Medica and Therapeutics. 
Twelfth edition. 8vo, 748 pages, . . . Price, cloth, $4.00 ; sheep, $4.50 

* The Eclectic Practice of Medicine for Families. 
Twenty-first edition, . . Price, $300; sheep, $4.00; half morocco, $5.00 

This work contains all of medicine that a family should know. It is 
Anatomy, Physiology, Hygiene, Practice, Materia Medica, Surgery and Ob- 
stetrics. It is concise, plain and correct, and will not lead to household 
drugging. Liberal offers to Agents. Write for terms. 

* Medicated Inhalaticns. 

Fourth edition, revised, with new Appendix, by Wm. Byrd Scud- 

der, M. D. 8vo, 159 pages, Price, cloth, $0.75 

" The inhalation of volatile medical substances is a rational method of 
treating diseases that have heretofore been monopolized by the quacks, and 
those who degrade the profession of medicine to a commercial level bj' 
newspaper advertising. The above book is an endeavor to raise the method 
to its proper level and field, and to study it scientifically."— Medical Visitor, 
Chicago, 



ECLECTIC TEXT-BOOKS. 



SCUDDER, JOHN K., M. D. 

* Eclectic Medical Journal. 

JOHN K. SCUDDER, M. D., Managing- Editor, assisted by the Faculty of 
the Eclectic Medical Institute. 

48 to 64 pages, monthly, " $2.00 per year, in advance 

The acknowledged organ of liberal medicine, and a strong advocate of 
the doctrines of Specific Medication. 



THOMAS, ROLLA L., M. D. 

Professor of the Practice of Medicine in the Eclectic Medical Institute, Cin- 
cinnati. 

(Issued 1906.) *The Eclectic Practice of Medicine. 

8vo, 1,033 pages, fully illustrated, .... Price, cloth, $6.00 ; sheep, $7.00 

Thomas' Practice is a monumental work. Its size and practical value 
make it this. No other work will be so nearly indispensable to the busy 
practitioner as a refresher, and wholly indispensable to the medical student. 
The old and experienced doctor could exist without it — the medical student 
can not do so and be just to himself. I confidently predict a phenomenal 
sale of this modern classic, and especially do I expect it to force its way into 
the eager hands of medical students. They can not finish their medical 
education without it. 

The Doctor's literary style is plain and simple, but strong and compel- 
ling. He has indulged in no dictioual scollops, no dizzy subtleties, and no 
vain theorizing — it is all straight, hard common sense. It throws a volume 
of light on Specific Medication that makes the work in a sense revelational. 
Dr. Thomas has put the medical world under a mountain of obligation to 
him. William Colby Cooper, M. D., Cleves, O. 

The mechanical part is fine. The grouping of diseases under their ap- 
propriate heads and arrangement of the subject matter enables the busy 
physician to find just what he wants without delay. 

Professor Thomas gives the history, etiology and pathology of diseases 
,ir\ so complete a manner that we have no need now (as heretofore) to con- 
sult the works of other schools on these points. Specific Medication, the 
Eclecticism of the present, is made prominent, while old and tried remedies 
are not discarded. Eclectics should be proud of this work. 

S. M. Sherman, M. D., Columbus, O. 



W ATKINS, LYMAN, M. D. 

Professor of Pathology and Physiology in the Eclectic Medical Institute. 

*A Compendium of the Practice of Medicine. 

Second edition. (Issued 1901.) i2mo, 460 pages, . Price, cloth, $2.50 net 

" The Compendium, in clear and concise language, gives a very excel- 
lent and suggestive repertory of the specific remedies indicated in the 
treatment of disease.'' — N. Y. Medical Times. 

"The Compendium or hand-book supplies an actual need, which please 
do not interpret as a perfunctory platitude. Without the pretension of 
more elaborate works on Theory and Practice, it is the practical elbow of 
the hurried every-day practitioner." — Eclectic Medical Gleaner. 

"A misconception of the whole idea of Specific Medication, which is 
rife in some directions, and which leads to its disci edit and condemnation, 
is, that Eclectics claim to have specifics for diseases, according- to the popular 
nomenclature, when in fact no such pretension has ever been made; and it 
has never been attempted to adapt the theory to certain combinations of 
symptoms which have received distinctive names as diseases,"— Medical 
Brief. 



ECLECTIC TEXT-BOOKS. 



WEBSTER, HERBERT T., M. D. 

Professor of the Principles of Medicine and Pathology in the California 
Eclectic Medical College, San Francisco, Cal. 

t The Principles of Medicine* 
8vo, 168 pages, Price, cloth, $1.50 

tThe Eclectic Practice of Medicine. 

8vo, 1,233 pages. 

New edition in 1902. Two volumes bound in one. 

Cloth, $6.50 j sheep, $7.50 



WILDER, ALEXANDER, M. D. 

t History of Medicine. 
Nearly 1,000 pages, 8vo, Price, cloth, $3.00 

An authentic history of the healing art from antiquity down to the pres- 
ent time. An exhaustive history of Eclectic Medicine. Intensely interest- 
ing. No physician's library complete without it. 



WINTERMUTE, ROBERT C, M. D. 

Late Professor of Obstetrics and Diseases of Women and Children in the 
Eclectic Medical Institute, Cincinnati. 

t American Eclectic Obstetrics. 
8 vo, 757 pages, . . ■ Price, sheep, $5.50 

A new edition of the standard edition of King's. Thoroughly revised 
and rewritten in 1890. 



WOODWARD, CHARLES, M. D. 

t Intra-Uterine Medication. 
i2mo, 208 pages. (Issued 1905), Price, cloth, $2.50 



